title: Catheter Ablation for Long-Standing Persistent Atrial Fibrillation.
abstract: Atrial fibrillation (AF) is the most common sustained arrhythmia worldwide and represents a major burden to health care systems. Atrial fibrillation is associated with a 4- to 5-fold increased risk of thromboembolic stroke. The pulmonary veins have been identified as major sources of atrial triggers for AF. This is particularly true in patients with paroxysmal AF but not always the case for those with long-standing persistent AF (LSPAF), in which other locations for ectopic beats have been well recognized. Structures with foci triggering AF include the coronary sinus, the left atrial appendage (LAA), the superior vena cava, the crista terminalis, and the ligament of Marshall. More than 30 studies reporting results on radiofrequency ablation of LSPAF have been published to date. Most of these are observational studies with very different methodologies using different strategies. As a result, there has been remarkable variation in short- and long-term success, which suggests that the optimal ablation technique for LSPAF is still to be elucidated. In this review we discuss the different approaches to LSPAF catheter ablation, starting with pulmonary vein isolation (PVI) through ablation lines in different left atrial locations, the role of complex fractionated atrial electrograms, focal impulses and rotor modulation, autonomic modulation (ganglionated plexi), alcohol ablation, and the future of epicardial mapping and ablation for this arrhythmia. A stepwise ablation approach requires several key ablation techniques, such as meticulous PVI, linear ablation at the roof and mitral isthmus, electrogram-targeted ablation with particular attention to triggers in the coronary sinus and LAA, and discretionary right atrial ablation (superior vena cava, intercaval, or cavotricuspid isthmus lines).
authors: Albert Einstein College of Medicine at Montefiore Hospital, Bronx, New York ; Ronald Reagan UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California.
authors: Jorge
authors: J
authors: Romero
authors: St. David's Medical Center, Austin, Texas ; University of Milan, Milan, Italy.
authors: Carola
authors: C
authors: Gianni
authors: Albert Einstein College of Medicine at Montefiore Hospital, Bronx, New York ; St. David's Medical Center, Austin, Texas ; University of Texas, Austin, Texas ; University of Foggia, Foggia, Italy.
authors: Luigi
authors: L
authors: Di Biase
authors: St. David's Medical Center, Austin, Texas ; University of Texas, Austin, Texas ; California Pacific Medical Center, San Francisco, California ; Stanford University, Palo Alto, California ; Case Western Reserve University, Cleveland, Ohio ; Scripps Clinic, San Diego, California.
authors: Andrea
authors: A
authors: Natale
mesh_terms: D055011:Ablation Techniques / Q000009:adverse effects; D000200:Action Potentials; D000818:Animals; D020517:Atrial Appendage / Q000503:physiopathology / Q000601:surgery*; D001281:Atrial Fibrillation / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D017115:Catheter Ablation / Q000009:adverse effects / Q000379:methods*; D022062:Electrophysiologic Techniques, Cardiac; D000431:Ethanol / Q000008:administration & dosage* / Q000009:adverse effects; D006329:Heart Conduction System / Q000503:physiopathology / Q000601:surgery*; D006339:Heart Rate; D006801:Humans; D011667:Pulmonary Veins / Q000503:physiopathology / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000431:Ethanol
keywords: atrial fibrillation; catheter ablation; complex fractionated atrial electrograms; linear ablation; long-standing persistent atrial fibrillation; pulmonary vein isolation