Pulmonary veins to left atrium cycle length gradient predicts procedural and clinical outcomes of persistent atrial fibrillation ablation.
BACKGROUND
Rapid pulmonary vein (PV) activity has been shown to maintain paroxysmal atrial fibrillation (AF). We evaluated in persistent AF the cycle length (CL) gradient between PVs and the left atrium (LA) in an attempt to identify the subset of patients where PVs play an important role.


RESULTS
Ninety-seven consecutive patients undergoing first ablation for persistent AF were studied. For each PV, the CL of the fastest activation was assessed over 1 minute (PVfast) using Lasso recordings. The PV to LA CL gradient was quantified by the ratio of PVfast to LA appendage (LAA) AF CL. Stepwise ablation terminated AF in 73 patients (75%). In the AF termination group, the PVfast CL was much shorter than the LAA CL resulting in lower PVfast/LAA ratios compared with the nontermination group (71±10% versus 92±7%; P<0.001). Within the termination group, PVfast/LAA ratios were notably lower if AF terminated after PV isolation or limited adjunctive substrate ablation compared with patients who required moderate or extensive ablation (63±6% versus 75±8%; P<0.001). PVfast/LAA ratio <69% predicted AF termination after PV isolation or limited substrate ablation with 74% positive predictive value and 95% negative predictive value. After a mean follow-up of 29±17 months, freedom from arrhythmia recurrence off-antiarrhythmic drugs was achieved in most patients with PVfast/LAA ratios <69% as opposed to the remaining population (80% versus 43%; P<0.001).


CONCLUSIONS
The PV to LA CL gradient may identify the subset of patients in whom persistent AF is likely to terminate after PV isolation or limited substrate ablation and better long-term outcomes are achieved.
From the Hôpital Cardiologique du Haut-Lévêque and Université Victor Segalen, Bordeaux II, France; and LIRYC Institute, Bordeaux, France. Patrizio.Pascale@chuv.ch.
Patrizio
P
Pascale
From the Hôpital Cardiologique du Haut-Lévêque and Université Victor Segalen, Bordeaux II, France; and LIRYC Institute, Bordeaux, France.
Ashok J
AJ
Shah
From the Hôpital Cardiologique du Haut-Lévêque and Université Victor Segalen, Bordeaux II, France; and LIRYC Institute, Bordeaux, France.
Laurent
L
Roten
From the Hôpital Cardiologique du Haut-Lévêque and Université Victor Segalen, Bordeaux II, France; and LIRYC Institute, Bordeaux, France.
Daniel
D
Scherr
From the Hôpital Cardiologique du Haut-Lévêque and Université Victor Segalen, Bordeaux II, France; and LIRYC Institute, Bordeaux, France.
Yuki
Y
Komatsu
From the Hôpital Cardiologique du Haut-Lévêque and Université Victor Segalen, Bordeaux II, France; and LIRYC Institute, Bordeaux, France.
Khaled
K
Ramoul
From the Hôpital Cardiologique du Haut-Lévêque and Université Victor Segalen, Bordeaux II, France; and LIRYC Institute, Bordeaux, France.
Matthew
M
Daly
From the Hôpital Cardiologique du Haut-Lévêque and Université Victor Segalen, Bordeaux II, France; and LIRYC Institute, Bordeaux, France.
Arnaud
A
Denis
From the Hôpital Cardiologique du Haut-Lévêque and Université Victor Segalen, Bordeaux II, France; and LIRYC Institute, Bordeaux, France.
Nicolas
N
Derval
From the Hôpital Cardiologique du Haut-Lévêque and Université Victor Segalen, Bordeaux II, France; and LIRYC Institute, Bordeaux, France.
Frédéric
F
Sacher
From the Hôpital Cardiologique du Haut-Lévêque and Université Victor Segalen, Bordeaux II, France; and LIRYC Institute, Bordeaux, France.
Mélèze
M
Hocini
From the Hôpital Cardiologique du Haut-Lévêque and Université Victor Segalen, Bordeaux II, France; and LIRYC Institute, Bordeaux, France.
Pierre
P
Jaïs
From the Hôpital Cardiologique du Haut-Lévêque and Université Victor Segalen, Bordeaux II, France; and LIRYC Institute, Bordeaux, France.
Michel
M
Haïssaguerre
D000368:Aged; D000704:Analysis of Variance; D001281:Atrial Fibrillation / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D018780:Body Surface Potential Mapping / Q000379:methods*; D017115:Catheter Ablation / Q000379:methods* / Q000401:mortality; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D006325:Heart Atria / Q000503:physiopathology; D006439:Hemodynamics / Q000502:physiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011446:Prospective Studies; D011667:Pulmonary Veins / Q000503:physiopathology* / Q000601:surgery*; D012008:Recurrence; D018570:Risk Assessment; D012720:Severity of Illness Index; D018709:Statistics, Nonparametric; D016019:Survival Analysis; D013997:Time Factors; D016896:Treatment Outcome
atrial fibrillation; cardiac electrophysiology; pulmonary veins