title: Active or passive pulmonary vein in atrial fibrillation: is pulmonary vein isolation always essential?
abstract: BACKGROUND
  The role of pulmonary veins (PVs) in persistent atrial fibrillation (AF) perpetuation appears less important than in paroxysmal AF. Electrogram-based substrate ablation is not widely performed as a stand-alone strategy.
  
  
  OBJECTIVE
  To evaluate PV activity in AF perpetuation and efficacy of our patient-tailored ablation strategy (electrogram-based substrate ablation with or without pulmonary vein isolation [PVI]).
  
  
  METHODS
  One hundred twenty-one patients with paroxysmal (n = 19; 15.7%), persistent (n = 77; 63.6%), or long-standing persistent (n = 25; 20.7%) AF underwent electrogram-based substrate ablation with AF termination end point: sinus rhythm or atrial tachycardia conversion. Before ablation, we classified PVs as "passive" if silent PV or if PV cycle length is greater than left atrial appendage cycle length. No PVI was performed in such cases.
  
  
  RESULTS
  Passive PVs were observed in 52 of 121 patients (paroxysmal AF = 0%, persistent AF = 40%, and long-standing persistent AF = 76%; P < .0001]). Substrate ablation terminated AF in 95.6% (sinus rhythm conversion in 80.2%). Compared with patients with active PVs, patients with passive PVs had longer AF sustained duration (19.1 ± 29.7 months vs 4.9 ± 11.1 months; P < .0001), larger left atrial diameter (46.9 ± 7.3 mm vs 41.9 ± 6.0 mm; P = .0014), lower left ventricular ejection fraction (45.4% ± 13.5% vs 55.1% ± 9.4%; P < .0001), and more often structural heart disease (57% vs 33%; P = .02). After a follow-up of 20.39 ± 11.23 months (1.6 procedures per patient), 82% were arrhythmia free with this strategy.
  
  
  CONCLUSIONS
  PV activity during AF decreases with AF chronicity, left atrial dilatation, and left ventricular ejection fraction. Our patient-tailored ablation strategy without systematic PVI provides good results.
authors.affiliation: Hôpital Saint Joseph, Marseille, France. Electronic address: jseitz@hopital-saint-joseph.fr.
authors.forename: Julien
authors.initials: J
authors.lastname: Seitz
authors.affiliation: Institut Cardiovasculaire Paris Sud, Hôpital Privé Jacques Cartier, Massy, France.
authors.forename: Jérôme
authors.initials: J
authors.lastname: Horvilleur
authors.affiliation: Hôpital Saint Joseph, Marseille, France.
authors.forename: Laurence
authors.initials: L
authors.lastname: Curel
authors.affiliation: Institut Cardiovasculaire Paris Sud, Hôpital Privé Jacques Cartier, Massy, France.
authors.forename: Jérôme
authors.initials: J
authors.lastname: Lacotte
authors.affiliation: Hôpital Saint Joseph, Marseille, France.
authors.forename: Alexandre
authors.initials: A
authors.lastname: Maluski
authors.affiliation: Hôpital Saint Joseph, Marseille, France.
authors.forename: Ange
authors.initials: A
authors.lastname: Ferracci
authors.affiliation: Hôpital Saint Joseph, Marseille, France.
authors.forename: Michel
authors.initials: M
authors.lastname: Bremondy
authors.affiliation: Institut Cardiovasculaire Paris Sud, Hôpital Privé Jacques Cartier, Massy, France.
authors.forename: Arnaud
authors.initials: A
authors.lastname: Rosier
authors.affiliation: Institut Cardiovasculaire Paris Sud, Hôpital Privé Jacques Cartier, Massy, France.
authors.forename: Mehran
authors.initials: M
authors.lastname: Monchi
authors.affiliation: Hôpital Saint Joseph, Marseille, France.
authors.forename: Guillaume
authors.initials: G
authors.lastname: Penaranda
authors.affiliation: Hôpital Saint Joseph, Marseille, France.
authors.forename: Jacques
authors.initials: J
authors.lastname: Faure
authors.affiliation: Hôpital Saint Joseph, Marseille, France.
authors.forename: Sylvain
authors.initials: S
authors.lastname: Beurtheret
authors.affiliation: Hôpital Saint Joseph, Marseille, France.
authors.forename: André
authors.initials: A
authors.lastname: Pisapia
mesh_terms: D001281:Atrial Fibrillation / Q000601:surgery*; D004562:Electrocardiography; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D011446:Prospective Studies; D011667:Pulmonary Veins / Q000503:physiopathology / Q000601:surgery*; D016896:Treatment Outcome
keywords: Arrhythmia; Atrial fibrillation; Catheter ablation; Complex fractionated atrial electrogram; Electrogram; Electrophysiology; Substrate