Small or Large Isolation Areas Around the Pulmonary Veins for the Treatment of Atrial Fibrillation?: Results From a Prospective Randomized Study Segmental pulmonary vein antrum isolation using the "large-size" lasso catheter in patients with atrial fibrillation. Pulmonary venous isolation by antral ablation with a large cryoballoon for treatment of paroxysmal and persistent atrial fibrillation: medium-term outcomes and non-randomised comparison with pulmonary venous isolation by radiofrequency ablation Electrical isolation of pulmonary veins in patients with atrial fibrillation: reduction of fluoroscopy exposure and procedure duration by the use of a non-fluoroscopic navigation system (NavX). Is Pulmonary Vein Isolation Necessary for Curing Atrial Fibrillation? Recurrence of pulmonary vein conduction and atrial fibrillation after pulmonary vein isolation for atrial fibrillation: a randomized trial of the ostial versus the extraostial ablation strategy. Phased-Array Intracardiac Echocardiography Monitoring During Pulmonary Vein Isolation in Patients With Atrial Fibrillation: Impact on Outcome and Complications Pulmonary vein isolation using segmental versus electroanatomical circumferential ablation for paroxysmal atrial fibrillation Pulmonary Vein Isolation for Paroxysmal and Persistent Atrial Fibrillation Pulmonary venous isolation versus additional substrate modification as treatment for paroxysmal atrial fibrillation Efficacy and safety of segmental ostial versus circumferential extra-ostial pulmonary vein isolation for atrial fibrillation. Surgical vs. transcatheter pulmonary vein isolation as first invasive treatment in patients with atrial fibrillation: a matched group comparison. Role of pulmonary veins isolation in persistent atrial fibrillation ablation: the pulmonary vein isolation in persistent atrial fibrillation (PIPA) study. Electrical isolation of the superior vena cava: an adjunctive strategy to pulmonary vein antrum isolation improving the outcome of AF ablation. Substrate modification combined with pulmonary vein isolation improves outcome of catheter ablation in patients with persistent atrial fibrillation: a prospective randomized comparison. Circumferential Radiofrequency Ablation of Pulmonary Vein Ostia: A New Anatomic Approach for Curing Atrial Fibrillation Pulmonary vein isolation and linear lesions in atrial fibrillation ablation
Background — Pulmonary vein ( PV ) isolation is a promising new treatment for  atrial fibrillation ( AF ) . We hypothesized that isolation of large areas around both ipsilateral PVs with verification of conduction block is more effective than the isolation of each individual PV . Methods and Results — A total of 110 patients , 67 with paroxysmal AF and 43 with persistent AF , were r and omly assigned to undergo either isolation of each individual PV or isolation of large areas around both ipsilateral PVs . The isolation of each individual PV was an electrophysiologically guided , ostial segmental ablation with a 64-pole basket catheter or a 20-pole circular mapping catheter ( group I ) . Isolation of large areas was performed around the 2 ipsilateral veins with a nonfluoroscopic navigation system and a circular 20-pole mapping catheter for verification of conduction block ( group II ) . In both groups , an irrigated-tip ablation catheter ( 25 to 35 W ) was used to achieve complete isolation . Procedure and ablation times were longer in group II , whereas fluoroscopic time was significantly shorter ( P≤0.001 ) . After a follow-up period of 15±4 months , 27 patients in group I ( 49 % ) and 37 patients in group II ( 67 % ) remained free of symptoms of AF and had no AF or atrial flutter during repetitive Holter monitoring without antiarrhythmic drug treatment after a single procedure ( P≤0.05 ) . Conclusions — The rate of success was significantly higher and fluoroscopy times were significantly lower in the group with large isolation areas around both ipsilateral PVs than in those who underwent individual PV isolation BACKGROUND The limited efficacy and complications of segmental ostial pulmonary vein isolation ( PVI ) for treating atrial fibrillation ( AF ) have been discussed so , in the present study the feasibility and efficiency of performing segmental pulmonary vein ( PV ) antrum isolation to treat AF were assessed . METHODS AND RESULTS A total of 187 patients with drug-refractory AF ( paroxysmal 120 , persistent 67 ) underwent segmental PVI guided by circumferential 20-electrode catheters ( Lasso ) . Radiofrequency ( RF ) current was delivered either at the ostium using a regular Lasso ( 15 - 20 mm in diameter , 70 patients : Group 1 ) or at the antrum using a larger Lasso ( 25 - 30 mm in diameter , 117 patients : Group 2 ) . A significantly wider region had to be ablated , with a longer RF application time , to isolate all 4 PVs in Group 2 patients than in Group 1 patients . Although the rate of recurrence of AF after the initial session was equal in both groups , a significantly greater number of patients were free from AF after a mean of 1.4 procedures in Group 2 than in Group 1 ( 93 % vs 76 % for paroxysmal AF , 78 % vs 48 % for persistent AF ) . CONCLUSIONS Segmental antral PVI using large-sized Lasso catheters was found to be more effective and safer than ostial PVI for the treatment of AF Background To prevent  atrial fibrillation ( AF ) recurrence after catheter ablation , pulmonary venous isolation ( PVI ) at an antral level is more effective than segmental ostial ablation . Cryoablation around the pulmonary venous ( PV ) ostia for AF therapy is potentially safer compared to radiofrequency ablation ( RFA ) . The aim of this study was to investigate the efficacy of a strategy using a large cryoablation balloon to perform antral cryoablation with ‘ touch-up ’ ostial cryoablation for PVI in patients with paroxysmal and persistent AF . Methods Paroxysmal and persistent AF patients undergoing their first left atrial ablation were recruited . After cryoballoon therapy , each PV was assessed for isolation and if necessary , treated with focal ostial cryoablation until PVI was achieved . Follow-up with Holter monitoring was performed . Clinical outcomes of the cryoablation protocol were compared , with consecutive patients undergoing PVI by RFA . Results 124 consecutive patients underwent cryoablation . 77 % of paroxysmal and 48 % of persistent AF subjects were free from AF at 12 months after a single procedure . Over the same time period , 53 consecutive paroxysmal AF subjects underwent PVI with RFA and at 12 months , 72 % were free from AF at 12 months ( p = NS ) . There were too few persistent AF subjects ( n=8 ) undergoing solely PVI by RFA as a comparison group . Procedural and fluoroscopic times during cryoablation were significantly shorter than RFA . Conclusions PV isolation can be achieved in less than 2 h by a simple cryoablation protocol with excellent results after a single intervention , particularly for paroxysmal AF AIMS The aim of the study was to investigate the feasibility of performing segmental pulmonary vein ( PV ) isolation guided by the NavX ( Endocardial Solutions , St Jude Medical , Inc. , St Paul , MN , USA ) system without the three-dimensional ( 3D ) geometric reconstruction option and whether the use of NavX system will reduce the radiation exposure and procedure duration . METHODS AND RESULTS The study included 64 patients with symptomatic paroxysmal or permanent atrial fibrillation , in whom PV isolation was performed using fluoroscopic guidance ( n=32 ) or the NavX system ( n=32 ) . Pulmonary vein mapping with a circular mapping catheter allowed the identification and localization of myocardial connections between the PV and the left atrium . PV isolation was performed by radiofrequency ablation of these connections at the atrial aspect of the PV ostium . Primary success rate for isolated PVs did not differ significantly in patients ablated under fluoroscopic guidance vs. those ablated under guidance of NavX system [ 100/107 PVs ( 93.5 % ) vs. 120/124 PV ( 96.8 % ; P = n.s . ) ] . Compared with fluoroscopy guided procedures , NavX-guided procedures showed a significant reduction in the fluoroscopy time ( 75.8+/-24.5 vs. 38.9+/-19.3 min , P<0.05 ) , total X-ray exposure ( 93.2+/-51.6 vs. 56.6+/-37.9 Gy cm(2 ) , P=0.03 ) , and total procedural time ( 237.7+/-65.4 vs. 188.6+/-62.7 min , P=0.01 ) . The mean follow-up was 9.5+/-3.0 months . One patient in each group was lost to follow-up . Seven-day Holter monitoring showed that 23 of 31 patients ( 74.2 % ) in the NavX-guided group and 21 of 31 patients ( 67.7 % ) in the fluoroscopy-guided group were in sinus rhythm ( P=0.57 ) . CONCLUSION The 3D visualization of the catheters by NavX system allows a rapid and precise visualization of the mapping and ablation catheters at the PV ostia and markedly reduces fluoroscopy time , total X-ray exposure , and procedural duration during PV isolation compared with ablation performed under fluoroscopy guidance Background —Pulmonary veins ( PVs ) play a pivotal role in initiating and perpetuating  atrial fibrillation ( AF ) . We investigated if PV electrical isolation from the left atrium is required for curing AF . Methods and Result —Fifty-one patients with paroxysmal or persistent AF underwent circumferential radiofrequency ablation of PV ostia performed with an anatomic approach . The end point of the ablation procedure was the recording of low peak-to-peak bipolar potentials ( < 0.1 mV ) inside the lesions . Left atrium pacing was used to assess the conduction between the PVs and the left atrium . During a mean follow-up period of 16.6±3.9 months , 41 patients ( 80.4 % ) were free of atrial arrhythmias . When patients with and without AF recurrence were analyzed , no significant difference was observed in the mean number of PVs in which the ablation end point was reached ( 3.4±1.2 versus 3.7±0.87 ) and PVs isolated ( 1.5±1.4 versus 1.6±1 ) . We noted that , although in 29 of 41 patients ( 71 % ) without AF recurrence , the ablation end point was reached in all PVs mapped , it was only possible to demonstrate the isolation of all PVs mapped in 2 patients . On the other h and , in 7 of 10 patients ( 70 % ) with AF recurrence , the ablation end point was reached in all PVs mapped , whereas one patient had all PVs isolated . Conclusions —Our findings show that with the use of a pure anatomic approach , it is possible to prevent AF in > 80 % of patients undergoing catheter ablation . Moreover , the isolation of PVs is not crucial for curing AF BACKGROUND Both segmental ostial and circumferential extraostial pulmonary vein ( PV ) isolation have been proven effective in the treatment of atrial fibrillation ( AF ) . However , the recurrence of AF and PV conduction after the 2 ablation strategies has never been compared in a r and omized study . METHODS A total of 100 consecutive patients ( age 56 + /- 10 ; 71 men ) with symptomatic AF ( paroxysmal , 51 ; persistent , 49 ) were r and omized to segmental ostial ( n = 54 ) or circumferential extraostial ( n = 46 ) PV isolation . A circular catheter positioned at the ostium of each target PV guided the ostial PV isolation . Extraostial PV isolation was performed by encircling the paired left and right PVs , respectively , guided by an electroanatomic mapping system . RESULTS A total of 84 % of the patients had recurrent AF after the first PV isolation procedure , showing 72 % with AF and 12 % with organized left atrial tachycardia . In patients undergoing reablation , all but 2 patients had recurrence of left atrium PV conduction ( > 95 % ) . During a mean follow-up of 12 months without antiarrhythmic medication , 57 % of patients who underwent extraostial PV isolation were free of arrhythmia symptoms compared with 31 % of patients who underwent ostial PV isolation ( P < .05 ) . This difference in success rate between the 2 ablation strategies was mainly seen in patients known with persistent AF ( 52 % and 15 % , respectively ; P = .02 ) as opposed to patients with paroxysmal AF ( 65 % and 46 % , respectively ; P = .26 ) . CONCLUSIONS Overall , the more proximal , extraostial PV isolation was found to be superior to ostial PV isolation , especially in patients known with persistent AF . A high recurrence rate of 84 % after a single complete PV isolation procedure was seen . At reablation , more than 95 % had recurrence of left atrium PV conduction regardless of the procedure used , supporting the idea that complete PV isolation seems essential to prevent arrhythmia recurrences Background —The objective of this study was to assess the impact of intracardiac echocardiography ( ICE ) on the long-term success and complications in patients undergoing pulmonary vein isolation ( PVI ) for treatment of atrial fibrillation ( AF ) . Methods and Results —Three hundred fifteen patients underwent PVI for treatment of AF . Each patient underwent ostial isolation of all PVs using a cooled-tip ablation catheter . PVI was performed using circular mapping ( CM ) alone ( group 1 , 56 patients ) , CM and ICE ( group 2 , 107 patients ) , and CM and ICE with titration of radiofrequency energy based on visualization of microbubbles by ICE ( group 3 , 152 patients ) . After a mean follow-up time of 417±145 days , 19.6 % ( 11 of 56 ) , 16.8 % ( 18 of 107 ) , and 9.8 % ( 15 of 152 ) of patients in groups 1 , 2 , and 3 experienced recurrence of AF , respectively . Moreover , whereas no group 3 patient experienced severe ( > 70 % ) PV stenosis , severe PV stenosis was documented in 3 ( 3.5 % ) of 56 patients in group 1 and in 2 ( 1.8 % ) of 107 patients in group 2 ( P < 0.05 ) . No embolic events were detected in group 3 patients . Conclusions —Intracardiac echocardiography improves the outcome of cooled-tip PVI . Power adjustment guided by direct visualization of microbubble formation reduces the risk of PV stenosis and improves long-term cure Purpose We tested the hypothesis that electroanatomic pulmonary vein ( PV ) antra encircling for the PV isolation will improve the outcome in treatment of paroxysmal atrial fibrillation ( PAF ) , compared with segmental PV isolation . Methods Fifty-four patients underwent segmental PV isolation ( group 1 ) and 56 patients circumferential PV isolation ( group 2 ) for symptomatic PAF in a r and omized study . Results Following single ablation procedure , at the 48 ± 8 month follow-up , 30 ( 56 % ) and 32 ( 57 % ) patients in groups 1 and 2 remained free of arrhythmia ( P = 0.41 ) . After repeat ablation , 43 ( 80 % ) and 45 ( 80 % ) patients in groups 1 and 2 were free of arrhythmia without antiarrhythmic drugs ( AADs ) ; 48 ( 89 % ) and 51 ( 91 % ) patients in groups 1 and 2 did not have arrhythmia recurrences without or with AADs . Conclusion This study demonstrates no advantage in long-term arrhythmia-free clinical outcome after circumferential PV isolation in patients with frequent PAF Background —The pulmonary veins ( PVs ) have been demonstrated to often play an important role in generating atrial fibrillation ( AF ) . The purpose of this study was to determine the safety and efficacy of segmental PV isolation in patients with paroxysmal or persistent AF . Methods and Results —In 70 consecutive patients ( mean age , 53±11 years ) with paroxysmal ( 58 ) or persistent ( 12 ) AF , segmental PV isolation guided by ostial PV potentials was performed . The left superior , left inferior , and right superior PVs were targeted for isolation in all patients , and the right inferior PV was isolated in 20 patients . Among the 230 targeted PVs , 217 ( 94 % ) were completely isolated , with a mean of 6.5±4.2 minutes of radiofrequency energy applied at a maximum power setting of 35 W. A second PV isolation procedure was performed in 6 patients ( 9 % ) . At 5 months of follow-up , 70 % of patients with paroxysmal and 22 % of patients with persistent AF were free from recurrent AF ( P < 0.001 ) , and 83 % of patients with paroxysmal AF were either free of symptomatic AF or had significant improvement . Among various clinical characteristics , only paroxysmal AF was an independent predictor of freedom from recurrence of AF ( P < 0.05 ) . One patient developed unilateral quadrantopsia after the procedure . There were no other complications . Conclusions —With a segmental isolation approach that targets at least 3 PVs , a clinical ly satisfactory result can be achieved in > 80 % of patients with paroxysmal AF . The clinical efficacy of pulmonary vein isolation is much lower when AF is persistent than when it is paroxysmal Background Pulmonary vein isolation alone is ineffective in maintaining sinus rhythm in up to one third of patients with paroxysmal atrial fibrillation ( AF ) . We compared pulmonary vein antral isolation plus additional limited ablation along the inferoposterior left atrium and epicardially within the adjacent coronary sinus ( PVAI + CS ) to pulmonary vein antral isolation ( PVAI ) alone in patients with paroxysmal AF . Methods Forty-two consecutive patients with paroxysmal AF were prospect ively r and omized to PVAI vs. PVAI + CS . All patients were seen 3 , 6 , 12 , and 18 months after ablation and underwent 24-h ambulatory Holter monitoring . Results Following a single procedure , 17 out of 22 patients ( 77 % ) remained arrhythmia free off antiarrhythmic medication after PVAI at 18 months vs. 10 out of 20 ( 50 % ) after PVAI + CS ( p < 0.01 ) . After PVAI , three patients had recurrent paroxysmal AF , and two had atrial tachycardia , whereas after PVAI + CS , three patients had recurrent paroxysmal AF , and seven had atrial tachycardia . All patients in the PVAI + CS group with atrial tachycardia who underwent a second procedure were found to have peri-mitral macro-reentry as the underlying mechanism . Eighty-one percent of patients remained arrhythmia free off medication after 1.09 procedures in the PVAI group vs. 80 % after 1.35 procedures in the PVAI + CS group ( p < 0.01 ) . Conclusion The addition of limited ablation along the inferoposterior left atrium and within the adjacent coronary sinus to PVAI alone did not reduce the recurrence rate of paroxysmal atrial fibrillation and was associated with an increased rate of peri-mitral macro-reentrant atrial tachycardia INTRODUCTION Pulmonary vein ( PV ) isolation for atrial fibrillation ( AF ) can be performed using a segmental ostial or a circumferential extra-ostial approach . The relative merits and potential limitations of each approach are currently debated . Here we report our early experience with each of these approaches , including their relative efficacy and safety . METHODS AND RESULTS Forty patients with drug-refractory AF underwent segmental ostial PV isolation and were compared to 40 consecutive patients who underwent PV isolation using a circumferential extra-ostial approach . The latter approach described here is novel in two aspects : ( 1 ) the endpoint for ablation was PV isolation and not only delay in left atrial to PV conduction time , and ( 2 ) isolation of the right and left PVs was achieved by a single encirclement of ipsilateral veins . At follow-up , 60 % of the patients in the segmental group were free of AF compared to 75 % of the patients in the circumferential group . There was one thromboembolic cerebrovascular complication during the ablation procedure in each group . CONCLUSION PV isolation using a circumferential extra-ostial approach , where the ipsilateral PVs are isolated together by one encircling line of block using electroanatomic mapping , is a technically feasible procedure . This approach is at least as effective and safe as the more established segmental ostial approach for AF ablation AIMS Pulmonary vein isolation ( PVI ) can be considered for treatment of symptomatic atrial fibrillation ( AF ) . Nowadays , in addition to transcatheter ablation , thoracoscopic surgical PVI is available . The aim of this study is to compare clinical outcome of surgical with transcatheter PVI as first invasive treatment strategy of AF . METHODS AND RESULTS From June 2009 to November 2011 , 33 patients underwent minimally invasive surgical PVI , and were matched ( 1:2 fashion ) retrospectively according to age , sex , and AF type , with 66 patients who underwent transcatheter PVI .  Success was defined as freedom from atrial arrhythmias on 24 h Holter monitoring without use of anti-arrhythmic drugs ( AADs ) at 1 year . Mean age was 52 ± 10 years , 82 % were male . Paroxysmal AF was present in 76 patients ( 77 % ) , persistent AF in 23 ( 23 % ) patients . None underwent prior ablations , and failed on 1.2 ± 0.6 AADs . At 12 months , complete freedom from atrial arrhythmias without AADs in the surgical PVI group was 88 % compared with 41 % in the transcatheter PVI group ( P < 0.001 ) . Freedom from atrial arrhythmias with AADs was 91 vs. 62 % , in the surgical vs. transcatheter PVI group , respectively ( P = 0.002 ) . Complications occurred in seven ( 21 % ) surgical PVI patients , and three ( 5 % ) transcatheter PVI patients ( P = 0.015 ) . CONCLUSION In present matched study comparing a surgical with transcatheter PVI treatment strategy in symptomatic AF patients failed on AADs , but without prior ablations , a surgical PVI strategy was more effective to prevent recurrence of atrial arrhythmias , than a transcatheter PVI treatment strategy . However , complications were more frequent with surgical PVI BACKGROUND The role of pulmonary veins ( PV ) isolation in patients with persistent atrial fibrillation ( AF ) is still debated . The aim of this study was to evaluate the adjunctive role of PV isolation in patients with persistent AF who underwent circumferential PV ablation ( anatomical approach ) . METHODS We treated 97 consecutive patients presenting with drug-refractory persistent AF by an anatomical approach ( group A , n = 36 , mean age = 60 + /- 8 years , 29 males ) or an integrated approach ( group B , n = 61 , mean age 59 + /- 10 years , 48 males ) . In all patients , radiofrequency ( RF ) ablation was performed by means of a nonfluoroscopic navigation system , in order to anatomically create circumferential lines around the PV . In group B , the persistence of PV potentials was ascertained with a multipolar circular catheter . If PV potentials persisted , RF energy targeting the electrophysiological breakthroughs was delivered to disconnect the PV . Past a 2-month period of observation , success was defined as absence of any atrial tachyarrhythmia recurrence lasting > 30 seconds . RESULTS Total procedure duration ( 220 + /- 62 minutes vs 140 + /- 43 minutes , P < 0.001 ) , fluoroscopy time ( 35 + /- 15 minutes vs 17 + /- 9 minutes , P < 0.001 ) , and RF delivery time ( 48 + /- 22 minutes vs 27 + /- 9 minutes , P < 0.001 ) were significantly longer in group B than in group A. One cardiac perforation occurred in group A. After 15 + /- 9.1 months , 21 patients in group A ( 58 % ) and 34 patients in group B ( 56 % ) were free of atrial tachyarrhythmia recurrence ( P = 0.9 ) . CONCLUSIONS In patients with persistent AF , who underwent an anatomical approach , electrophysiological confirmation of PV disconnection significantly increased the fluoroscopy and procedural times , without effect on the long-term outcomes UNLABELLED PV isolation at the antrum ( PVAI ) has improved safety and efficacy of ablation procedures for atrial fibrillation ( AF ) . AF triggers from the superior vena cava ( SVC ) may compromise the outcome of PVAI . PURPOSE We evaluated the ( 1 ) incidence of SVC triggers , ( 2 ) feasibility of empiric SVC electrical isolation ( SVCI )  as an adjunct to PVAI , and ( 3 ) SVCI safety . METHODS AND RESULTS Of 190 patients ( group I ) , 24 ( 12 % ) showed SVC triggers . Following PVAI , seven patients had AT originating from the SVC and three had AF . After SVCI , all 24 patients were  arrhythmia-free  450 + /- 180 days post procedure . In the subsequent 217 patients ( group II ) , empirical SVCI was performed following PVAI . Sixty-six of all 407 patients ( 16 % ) experienced recurrence of AF . A repeat procedure in 25 of the 66 patients showed that five ( 20 % ) had AF recurrence initiated by SVC triggers , of whom four were among group I patients ( 4/190 ; 2 % ) and one was from group II ( 1/217 ; 0.4 % ) , ( P < 0.05 ) . Transient diaphragmatic paralysis can be avoided by pacing at the lateral aspect of the SVC using high output ( 30 mA ) . There was no SVC stenosis on CT scans before or 3 months after the procedure . There was no sinus node injury . CONCLUSIONS The SVC harbors the majority of non-PV triggers of AF . SVCI is feasible , safe , and may be considered as an adjunctive strategy to PVAI for ablation of AF . The long-term favorable outcome of this hybrid approach remains to be evaluated in a larger series of patients AIMS To investigate the effectiveness of additional substrate modification ( SM ) by left atrial ( LA ) linear lesions as compared with pulmonary vein isolation ( PVI ) alone in patients with persistent atrial fibrillation ( AF ) in a prospect i ve r and omized study . Percutaneous PVI has evolved as an accepted treatment for paroxysmal AF but seemed to be less effective in patients with persistent AF . The benefit of PVI alone and additional linear lesions has not been vali date d in a r and omized study so far . METHODS AND RESULTS Sixty-two patients with persistent AF ( median duration 7 , range 1 - 18 months ) were r and omly assigned to either PVI alone ( n = 30 ) or additional SM ( n = 32 ) consisting of a roof line connecting both left superior and right superior PV and LA isthmus ablation between left inferior PV and mitral annulus . Procedures including SM were performed using a three-dimensional mapping system ( EnSite NavX , St Jude Medical , St Paul , MN , USA ) . Anti-arrhythmic drugs were discontinued within 8 weeks after ablation in both groups . Follow-up included daily trans-telephonic ECG transmitted irrespective of the patient 's symptoms . PVI was successful in 98 % of all targeted veins in both groups . Additional SM did not increase fluoroscopy time ( 72.1+/-18.7 vs. 72.9+/-17.3 min , P=0.92 ) because of the use of three-dimensional navigation in the PVI+SM group . AF recurrences within the first 4 weeks following ablation were more common after PVI alone ( 77 % ) than additional SM ( 44 % , P=0.002 ) . After a follow-up time of 487 ( 429 - 570 ) days , only 20 % of patients undergoing st and alone PVI  remained in sinus rhythm when compared with 69 % following PVI combined with SM ( P=0.0001 ) . Two patients assigned to PVI+SM experienced procedure-related complications ( cardiac tamponade and minor stroke ) which resolved without sequelae . CONCLUSION PVI alone is insufficient in the treatment of persistent AF . However , additional left linear lesions increase the success rate significantly . Early AF-relapses are associated with a negative outcome after PVI alone but not following additional SM Background —The pulmonary veins ( PVs ) and surrounding ostial areas frequently house focal triggers or reentrant circuits critical to the genesis of atrial fibrillation ( AF ) . We developed an anatomic approach aim ed at isolating each PV from the left atrium ( LA ) by circumferential radiofrequency ( RF ) lesions around their ostia . Methods and Results —We selected 26 patients with resistant AF , either paroxysmal ( n=14 ) or permanent ( n=12 ) . A nonfluoroscopic mapping system was used to generate 3D electroanatomic LA maps and deliver RF energy . Two maps were acquired during coronary sinus and right atrial pacing to vali date the lateral and septal PV lesions , respectively . Patients were followed up closely for ≥6 months . Procedures lasted 290±58 minutes , including 80±22 minutes for acquisition of all maps , and 118±16 RF pulses were deployed . Among 14 patients in AF at the beginning of the procedure , 64 % had sinus rhythm restoration during ablation . PV isolation was demonstrated in 76 % of 104 PVs treated by low peak-to-peak electrogram amplitude ( 0.08±0.02 mV ) inside the circular line and by disparity in activation times ( 58±11 ms ) across the lesion . After 9±3 months , 22 patients ( 85 % ) were AF-free , including 62 % not taking and 23 % taking antiarrhythmic drugs , with no difference ( P = NS ) between paroxysmal and permanent AF . No thromboembolic events or PV stenoses were observed by transesophageal echocardiography . Conclusions —Radiofrequency PV isolation with electroanatomic guidance is safe and effective in either paroxysmal or permanent AF Background Various strategies have been used for atrial fibrillation ( AF ) ablation . It is unclear whether adding linear lesions to pulmonary vein ( PV ) isolation has significant advantages . Objectives We assessed the clinical benefit of adding linear lesions in patients undergoing PV isolation for AF . Methods One hundred patients ( 63 male and 37 female ; mean age of 59 ± 11 years ) with documented paroxysmal AF were included in the study . Patients were r and omized into two groups . The first group underwent PV isolation alone . The second group underwent PV isolation and had two linear lesions created ; one line between the superior PVs , and a second line from the left inferior PV to the mitral valve annulus . Patients ’ clinical progress after the ablation was evaluated and compared at 1 , 3 , and 9 months after their respective ablation procedures . Results The linear lesions group maintained sinus rhythm and had fewer symptoms than the lone PV isolation group ( 86 vs. 58 % , respectively ) ( p < 0.05 ) at 1 month . At 9 months , when patients who reverted to AF underwent additional management to regain sinus rhythm ( 90 vs. 82 % , respectively ) ( p = NS ) , there was no statistical difference between the groups regarding the use of antiarrhythmics , the need for electrical cardioversion , and subjective improvement . Conclusion The addition of linear lesions to PV isolation more effectively achieved sinus rhythm initially and fewer patients required additional management to maintain their rhythm when compared to patients who underwent lone PV isolation . However , at 9 months , the overall results were similar in both groups
Our primary finding is that PVI performed with a wide antral approach is more effective than ostial PVI in achieving freedom from total atrial tachyarrhythmia recurrence at long-term follow-up
BACKGROUND For the past decade , electric pulmonary vein isolation ( PVI ) has become a procedure implemented worldwide for the treatment of atrial fibrillation .
Currently , 2 main approaches are used for PVI : ostial isolation of the PVs and wide antral PVI .
The aims of this systematic review are to evaluate the relative merits of each technique with a pooled comparative analysis of efficacy and complications .