title: Ablation of Persistent Atrial Fibrillation Targeting Low-Voltage Areas With Selective Activation Characteristics.
abstract: Complex-fractionated atrial electrograms and atrial fibrosis are associated with maintenance of persistent atrial fibrillation (AF). We hypothesized that pulmonary vein isolation (PVI) plus ablation of selective atrial low-voltage sites may be more successful than PVI only.
  
  
  
  A total of 85 consecutive patients with persistent AF underwent high-density atrial voltage mapping, PVI, and ablation at low-voltage areas (LVA < 0.5 mV in AF) associated with electric activity lasting > 70% of AF cycle length on a single electrode (fractionated activity) or multiple electrodes around the circumferential mapping catheter (rotational activity) or discrete rapid local activity (group I). The procedural end point was AF termination. Arrhythmia freedom was compared with a control group (66 patients) undergoing PVI only (group II). PVI alone was performed in 23 of 85 (27%) patients of group I with low amount (< 10% of left atrial surface area) of atrial low voltage. Selective atrial ablation in addition to PVI was performed in 62 patients with termination of AF in 45 (73%) after 11 ± 9 minutes radiofrequency delivery. AF-termination sites colocalized within LVA in 80% and at border zones in 20%. Single-procedural arrhythmia freedom at 13 months median follow-up was achieved in 59 of 85 (69%) patients in group I, which was significantly higher than the matched control group (31/66 [47%], P < 0.001). There was no significant difference in the success rate of patients in group I with a low amount of low voltage undergoing PVI only and patients requiring PVI+selective low-voltage ablation (P = 0.42).
  
  
  
  Ablation of sites with distinct activation characteristics within/at borderzones of LVA in addition to PVI is more effective than conventional PVI-only strategy for persistent AF. PVI only seems to be sufficient to treat patients with left atrial low voltage < 10%.
authors.affiliation: Arrhythmia Division, Department of Cardiology and Angiology (A.S.J., H.L., J.S., V.M., J.M., C.-I.P., C.P., J.A., W.H., C.H.-S., Y.E.O., F.-J.N., R.W., T.A.) and Department of Anesthesiology (C.K.), University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany; Arrhythmia Department, University Hospital Haut-Leveque Bordeaux, Pessac, France (A.D., P.J., M.H., M.H.); and Arrhythmia Division, St. Jude Medical, St. Paul, MN (S.K.). amir.jadidi@universitaets-herzzentrum.de.
authors.forename: Amir S
authors.initials: AS
authors.lastname: Jadidi
authors.affiliation: Arrhythmia Division, Department of Cardiology and Angiology (A.S.J., H.L., J.S., V.M., J.M., C.-I.P., C.P., J.A., W.H., C.H.-S., Y.E.O., F.-J.N., R.W., T.A.) and Department of Anesthesiology (C.K.), University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany; Arrhythmia Department, University Hospital Haut-Leveque Bordeaux, Pessac, France (A.D., P.J., M.H., M.H.); and Arrhythmia Division, St. Jude Medical, St. Paul, MN (S.K.).
authors.forename: Heiko
authors.initials: H
authors.lastname: Lehrmann
authors.affiliation: Arrhythmia Division, Department of Cardiology and Angiology (A.S.J., H.L., J.S., V.M., J.M., C.-I.P., C.P., J.A., W.H., C.H.-S., Y.E.O., F.-J.N., R.W., T.A.) and Department of Anesthesiology (C.K.), University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany; Arrhythmia Department, University Hospital Haut-Leveque Bordeaux, Pessac, France (A.D., P.J., M.H., M.H.); and Arrhythmia Division, St. Jude Medical, St. Paul, MN (S.K.).
authors.forename: Cornelius
authors.initials: C
authors.lastname: Keyl
authors.affiliation: Arrhythmia Division, Department of Cardiology and Angiology (A.S.J., H.L., J.S., V.M., J.M., C.-I.P., C.P., J.A., W.H., C.H.-S., Y.E.O., F.-J.N., R.W., T.A.) and Department of Anesthesiology (C.K.), University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany; Arrhythmia Department, University Hospital Haut-Leveque Bordeaux, Pessac, France (A.D., P.J., M.H., M.H.); and Arrhythmia Division, St. Jude Medical, St. Paul, MN (S.K.).
authors.forename: Jérémie
authors.initials: J
authors.lastname: Sorrel
authors.affiliation: Arrhythmia Division, Department of Cardiology and Angiology (A.S.J., H.L., J.S., V.M., J.M., C.-I.P., C.P., J.A., W.H., C.H.-S., Y.E.O., F.-J.N., R.W., T.A.) and Department of Anesthesiology (C.K.), University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany; Arrhythmia Department, University Hospital Haut-Leveque Bordeaux, Pessac, France (A.D., P.J., M.H., M.H.); and Arrhythmia Division, St. Jude Medical, St. Paul, MN (S.K.).
authors.forename: Viktor
authors.initials: V
authors.lastname: Markstein
authors.affiliation: Arrhythmia Division, Department of Cardiology and Angiology (A.S.J., H.L., J.S., V.M., J.M., C.-I.P., C.P., J.A., W.H., C.H.-S., Y.E.O., F.-J.N., R.W., T.A.) and Department of Anesthesiology (C.K.), University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany; Arrhythmia Department, University Hospital Haut-Leveque Bordeaux, Pessac, France (A.D., P.J., M.H., M.H.); and Arrhythmia Division, St. Jude Medical, St. Paul, MN (S.K.).
authors.forename: Jan
authors.initials: J
authors.lastname: Minners
authors.affiliation: Arrhythmia Division, Department of Cardiology and Angiology (A.S.J., H.L., J.S., V.M., J.M., C.-I.P., C.P., J.A., W.H., C.H.-S., Y.E.O., F.-J.N., R.W., T.A.) and Department of Anesthesiology (C.K.), University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany; Arrhythmia Department, University Hospital Haut-Leveque Bordeaux, Pessac, France (A.D., P.J., M.H., M.H.); and Arrhythmia Division, St. Jude Medical, St. Paul, MN (S.K.).
authors.forename: Chan-Il
authors.initials: CI
authors.lastname: Park
authors.affiliation: Arrhythmia Division, Department of Cardiology and Angiology (A.S.J., H.L., J.S., V.M., J.M., C.-I.P., C.P., J.A., W.H., C.H.-S., Y.E.O., F.-J.N., R.W., T.A.) and Department of Anesthesiology (C.K.), University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany; Arrhythmia Department, University Hospital Haut-Leveque Bordeaux, Pessac, France (A.D., P.J., M.H., M.H.); and Arrhythmia Division, St. Jude Medical, St. Paul, MN (S.K.).
authors.forename: Arnaud
authors.initials: A
authors.lastname: Denis
authors.affiliation: Arrhythmia Division, Department of Cardiology and Angiology (A.S.J., H.L., J.S., V.M., J.M., C.-I.P., C.P., J.A., W.H., C.H.-S., Y.E.O., F.-J.N., R.W., T.A.) and Department of Anesthesiology (C.K.), University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany; Arrhythmia Department, University Hospital Haut-Leveque Bordeaux, Pessac, France (A.D., P.J., M.H., M.H.); and Arrhythmia Division, St. Jude Medical, St. Paul, MN (S.K.).
authors.forename: Pierre
authors.initials: P
authors.lastname: Jaïs
authors.affiliation: Arrhythmia Division, Department of Cardiology and Angiology (A.S.J., H.L., J.S., V.M., J.M., C.-I.P., C.P., J.A., W.H., C.H.-S., Y.E.O., F.-J.N., R.W., T.A.) and Department of Anesthesiology (C.K.), University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany; Arrhythmia Department, University Hospital Haut-Leveque Bordeaux, Pessac, France (A.D., P.J., M.H., M.H.); and Arrhythmia Division, St. Jude Medical, St. Paul, MN (S.K.).
authors.forename: Mélèze
authors.initials: M
authors.lastname: Hocini
authors.affiliation: Arrhythmia Division, Department of Cardiology and Angiology (A.S.J., H.L., J.S., V.M., J.M., C.-I.P., C.P., J.A., W.H., C.H.-S., Y.E.O., F.-J.N., R.W., T.A.) and Department of Anesthesiology (C.K.), University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany; Arrhythmia Department, University Hospital Haut-Leveque Bordeaux, Pessac, France (A.D., P.J., M.H., M.H.); and Arrhythmia Division, St. Jude Medical, St. Paul, MN (S.K.).
authors.forename: Clemens
authors.initials: C
authors.lastname: Potocnik
authors.affiliation: Arrhythmia Division, Department of Cardiology and Angiology (A.S.J., H.L., J.S., V.M., J.M., C.-I.P., C.P., J.A., W.H., C.H.-S., Y.E.O., F.-J.N., R.W., T.A.) and Department of Anesthesiology (C.K.), University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany; Arrhythmia Department, University Hospital Haut-Leveque Bordeaux, Pessac, France (A.D., P.J., M.H., M.H.); and Arrhythmia Division, St. Jude Medical, St. Paul, MN (S.K.).
authors.forename: Juergen
authors.initials: J
authors.lastname: Allgeier
authors.affiliation: Arrhythmia Division, Department of Cardiology and Angiology (A.S.J., H.L., J.S., V.M., J.M., C.-I.P., C.P., J.A., W.H., C.H.-S., Y.E.O., F.-J.N., R.W., T.A.) and Department of Anesthesiology (C.K.), University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany; Arrhythmia Department, University Hospital Haut-Leveque Bordeaux, Pessac, France (A.D., P.J., M.H., M.H.); and Arrhythmia Division, St. Jude Medical, St. Paul, MN (S.K.).
authors.forename: Willibald
authors.initials: W
authors.lastname: Hochholzer
authors.affiliation: Arrhythmia Division, Department of Cardiology and Angiology (A.S.J., H.L., J.S., V.M., J.M., C.-I.P., C.P., J.A., W.H., C.H.-S., Y.E.O., F.-J.N., R.W., T.A.) and Department of Anesthesiology (C.K.), University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany; Arrhythmia Department, University Hospital Haut-Leveque Bordeaux, Pessac, France (A.D., P.J., M.H., M.H.); and Arrhythmia Division, St. Jude Medical, St. Paul, MN (S.K.).
authors.forename: Claudia
authors.initials: C
authors.lastname: Herrera-Siklody
authors.affiliation: Arrhythmia Division, Department of Cardiology and Angiology (A.S.J., H.L., J.S., V.M., J.M., C.-I.P., C.P., J.A., W.H., C.H.-S., Y.E.O., F.-J.N., R.W., T.A.) and Department of Anesthesiology (C.K.), University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany; Arrhythmia Department, University Hospital Haut-Leveque Bordeaux, Pessac, France (A.D., P.J., M.H., M.H.); and Arrhythmia Division, St. Jude Medical, St. Paul, MN (S.K.).
authors.forename: Steve
authors.initials: S
authors.lastname: Kim
authors.affiliation: Arrhythmia Division, Department of Cardiology and Angiology (A.S.J., H.L., J.S., V.M., J.M., C.-I.P., C.P., J.A., W.H., C.H.-S., Y.E.O., F.-J.N., R.W., T.A.) and Department of Anesthesiology (C.K.), University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany; Arrhythmia Department, University Hospital Haut-Leveque Bordeaux, Pessac, France (A.D., P.J., M.H., M.H.); and Arrhythmia Division, St. Jude Medical, St. Paul, MN (S.K.).
authors.forename: Youssef El
authors.initials: YE
authors.lastname: Omri
authors.affiliation: Arrhythmia Division, Department of Cardiology and Angiology (A.S.J., H.L., J.S., V.M., J.M., C.-I.P., C.P., J.A., W.H., C.H.-S., Y.E.O., F.-J.N., R.W., T.A.) and Department of Anesthesiology (C.K.), University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany; Arrhythmia Department, University Hospital Haut-Leveque Bordeaux, Pessac, France (A.D., P.J., M.H., M.H.); and Arrhythmia Division, St. Jude Medical, St. Paul, MN (S.K.).
authors.forename: Franz-Josef
authors.initials: FJ
authors.lastname: Neumann
authors.affiliation: Arrhythmia Division, Department of Cardiology and Angiology (A.S.J., H.L., J.S., V.M., J.M., C.-I.P., C.P., J.A., W.H., C.H.-S., Y.E.O., F.-J.N., R.W., T.A.) and Department of Anesthesiology (C.K.), University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany; Arrhythmia Department, University Hospital Haut-Leveque Bordeaux, Pessac, France (A.D., P.J., M.H., M.H.); and Arrhythmia Division, St. Jude Medical, St. Paul, MN (S.K.).
authors.forename: Reinhold
authors.initials: R
authors.lastname: Weber
authors.affiliation: Arrhythmia Division, Department of Cardiology and Angiology (A.S.J., H.L., J.S., V.M., J.M., C.-I.P., C.P., J.A., W.H., C.H.-S., Y.E.O., F.-J.N., R.W., T.A.) and Department of Anesthesiology (C.K.), University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany; Arrhythmia Department, University Hospital Haut-Leveque Bordeaux, Pessac, France (A.D., P.J., M.H., M.H.); and Arrhythmia Division, St. Jude Medical, St. Paul, MN (S.K.).
authors.forename: Michel
authors.initials: M
authors.lastname: Haïssaguerre
authors.affiliation: Arrhythmia Division, Department of Cardiology and Angiology (A.S.J., H.L., J.S., V.M., J.M., C.-I.P., C.P., J.A., W.H., C.H.-S., Y.E.O., F.-J.N., R.W., T.A.) and Department of Anesthesiology (C.K.), University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany; Arrhythmia Department, University Hospital Haut-Leveque Bordeaux, Pessac, France (A.D., P.J., M.H., M.H.); and Arrhythmia Division, St. Jude Medical, St. Paul, MN (S.K.).
authors.forename: Thomas
authors.initials: T
authors.lastname: Arentz
mesh_terms: D000200:Action Potentials; D000368:Aged; D001281:Atrial Fibrillation / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D017115:Catheter Ablation / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D018572:Disease-Free Survival; D004566:Electrodes; D022062:Electrophysiologic Techniques, Cardiac; D005260:Female; D005355:Fibrosis; D006329:Heart Conduction System / Q000473:pathology / Q000503:physiopathology / Q000601:surgery*; D006339:Heart Rate; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D011446:Prospective Studies; D011667:Pulmonary Veins / Q000503:physiopathology / Q000601:surgery*; D012008:Recurrence; D012074:Remission Induction; D013997:Time Factors; D016896:Treatment Outcome
keywords: AF sources; atrial fibrillation; catheter ablation; fibrosis; low voltage; rotational activity