title: Determinants of Acute and Late Pulmonary Vein Reconnection in Contact Force-Guided Pulmonary Vein Isolation: Identifying the Weakest Link in the Ablation Chain.
abstract: BACKGROUND
  Pulmonary vein reconnection (PVR) still determines recurrences of atrial fibrillation after contact force (CF)-guided pulmonary vein isolation. We studied whether acute PVR (adenosine and waiting time) and late PVR (at repeat) are explained by incomplete transmurality and contiguity within the deployed radiofrequency circle.
  
  
  RESULTS
  We analyzed 42 CF-guided ipsilateral pulmonary vein isolation procedures. For each radiofrequency tag within the circle, we collected data reflecting lesion depth (time of application, power, impedance drop [Δ-Imp], CF, force-time integral [FTI], and ablation index [AI]) and contiguity (automated interlesion distance [ILD]). Ablation line contiguity index (ALCI) was developed as a novel automated algorithm combining depth and contiguity into one single criterion. Each circle was subdivided into 10 segments. For each segment, we determined its weakest link by annotating timemin, powermin, Δ-Impmin, CFmin, FTImin, AImin, ILDmax, and ALCImin. Compared with segments without PVR (n=758), PVR segments (n=44) were characterized by lower Δ-Impmin(4.8 versus 7.4 Ω), CFmin(8.5 versus 11.8 g), FTImin(351 versus 473 gs), AImin(367 versus 408 arbitrary unit [au]), and higher ILDmax(6.8 versus 5.5 mm). ALCIminwas significantly lower in segments with PVR (74% versus 104%;P<0.001) and was associated with the highest accuracy to predict durable segments (area under the curve=0.73).
  
  
  CONCLUSIONS
  In CF-guided pulmonary vein isolation, PVR is explained by lack of both lesion depth and contiguity within the deployed radiofrequency circle. ALCI, a novel measure combing contiguity and depth, is the most accurate predictor for durable segments. By avoiding weak links in the ablation chain, ALCI-guided ablation is expected to improve success rate of point-by-point radiofrequency ablation.
authors.affiliation: From the Department of Cardiology, Sint-Jan Hospital Bruges, Belgium (M.E.H., P.T., T.P., M.W., R.C., S.K., Y.V., R.T., M.D.); Department of Internal Medicine, Ghent University, Belgium (M.E.H., A.D., M.D.); and Heart Rhythm Institute and Department of Medicine, University of Oklahoma Health Sciences Center (H.N.).
authors.forename: Milad
authors.initials: M
authors.lastname: El Haddad
authors.affiliation: From the Department of Cardiology, Sint-Jan Hospital Bruges, Belgium (M.E.H., P.T., T.P., M.W., R.C., S.K., Y.V., R.T., M.D.); Department of Internal Medicine, Ghent University, Belgium (M.E.H., A.D., M.D.); and Heart Rhythm Institute and Department of Medicine, University of Oklahoma Health Sciences Center (H.N.).
authors.forename: Philippe
authors.initials: P
authors.lastname: Taghji
authors.affiliation: From the Department of Cardiology, Sint-Jan Hospital Bruges, Belgium (M.E.H., P.T., T.P., M.W., R.C., S.K., Y.V., R.T., M.D.); Department of Internal Medicine, Ghent University, Belgium (M.E.H., A.D., M.D.); and Heart Rhythm Institute and Department of Medicine, University of Oklahoma Health Sciences Center (H.N.).
authors.forename: Thomas
authors.initials: T
authors.lastname: Phlips
authors.affiliation: From the Department of Cardiology, Sint-Jan Hospital Bruges, Belgium (M.E.H., P.T., T.P., M.W., R.C., S.K., Y.V., R.T., M.D.); Department of Internal Medicine, Ghent University, Belgium (M.E.H., A.D., M.D.); and Heart Rhythm Institute and Department of Medicine, University of Oklahoma Health Sciences Center (H.N.).
authors.forename: Michael
authors.initials: M
authors.lastname: Wolf
authors.affiliation: From the Department of Cardiology, Sint-Jan Hospital Bruges, Belgium (M.E.H., P.T., T.P., M.W., R.C., S.K., Y.V., R.T., M.D.); Department of Internal Medicine, Ghent University, Belgium (M.E.H., A.D., M.D.); and Heart Rhythm Institute and Department of Medicine, University of Oklahoma Health Sciences Center (H.N.).
authors.forename: Anthony
authors.initials: A
authors.lastname: Demolder
authors.affiliation: From the Department of Cardiology, Sint-Jan Hospital Bruges, Belgium (M.E.H., P.T., T.P., M.W., R.C., S.K., Y.V., R.T., M.D.); Department of Internal Medicine, Ghent University, Belgium (M.E.H., A.D., M.D.); and Heart Rhythm Institute and Department of Medicine, University of Oklahoma Health Sciences Center (H.N.).
authors.forename: Rajin
authors.initials: R
authors.lastname: Choudhury
authors.affiliation: From the Department of Cardiology, Sint-Jan Hospital Bruges, Belgium (M.E.H., P.T., T.P., M.W., R.C., S.K., Y.V., R.T., M.D.); Department of Internal Medicine, Ghent University, Belgium (M.E.H., A.D., M.D.); and Heart Rhythm Institute and Department of Medicine, University of Oklahoma Health Sciences Center (H.N.).
authors.forename: Sébastien
authors.initials: S
authors.lastname: Knecht
authors.affiliation: From the Department of Cardiology, Sint-Jan Hospital Bruges, Belgium (M.E.H., P.T., T.P., M.W., R.C., S.K., Y.V., R.T., M.D.); Department of Internal Medicine, Ghent University, Belgium (M.E.H., A.D., M.D.); and Heart Rhythm Institute and Department of Medicine, University of Oklahoma Health Sciences Center (H.N.).
authors.forename: Yves
authors.initials: Y
authors.lastname: Vandekerckhove
authors.affiliation: From the Department of Cardiology, Sint-Jan Hospital Bruges, Belgium (M.E.H., P.T., T.P., M.W., R.C., S.K., Y.V., R.T., M.D.); Department of Internal Medicine, Ghent University, Belgium (M.E.H., A.D., M.D.); and Heart Rhythm Institute and Department of Medicine, University of Oklahoma Health Sciences Center (H.N.).
authors.forename: Rene
authors.initials: R
authors.lastname: Tavernier
authors.affiliation: From the Department of Cardiology, Sint-Jan Hospital Bruges, Belgium (M.E.H., P.T., T.P., M.W., R.C., S.K., Y.V., R.T., M.D.); Department of Internal Medicine, Ghent University, Belgium (M.E.H., A.D., M.D.); and Heart Rhythm Institute and Department of Medicine, University of Oklahoma Health Sciences Center (H.N.).
authors.forename: Hiroshi
authors.initials: H
authors.lastname: Nakagawa
authors.affiliation: From the Department of Cardiology, Sint-Jan Hospital Bruges, Belgium (M.E.H., P.T., T.P., M.W., R.C., S.K., Y.V., R.T., M.D.); Department of Internal Medicine, Ghent University, Belgium (M.E.H., A.D., M.D.); and Heart Rhythm Institute and Department of Medicine, University of Oklahoma Health Sciences Center (H.N.). mattias.duytschaever@azsintjan.be.
authors.forename: Mattias
authors.initials: M
authors.lastname: Duytschaever
mesh_terms: D000368:Aged; D000714:Anastomosis, Surgical / Q000009:adverse effects / Q000379:methods; D001281:Atrial Fibrillation / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D017115:Catheter Ablation / Q000009:adverse effects / Q000379:methods*; D015331:Cohort Studies; D016208:Databases, Factual; D004562:Electrocardiography; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D011667:Pulmonary Veins / Q000601:surgery*; D012008:Recurrence; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D015996:Survival Rate; D016896:Treatment Outcome
keywords: algorithm; atrial fibrillation; catheter ablation; freedom; pulmonary vein