A Comparative Study Of Different Ablation Strategies For Focal Atrial Tachycardia Originating From Pulmonary Veins

Objective:To evaluate the efficiency and safety of three different ablation methods which are focal ablation,single pulmonary vein isolation and circumferential pulmonary vein isolation respectively,for focal atrial tachycardia originating from pulmonary veins.Methods:We reviewed 45 consecutive patients who underwent pulmonary vein ATs radiofrequency ablation at our institution from July 2011 to September 2017,they were consist of 26 males and 19 females,with symptoms for 6.51 ± 3.99 months(range 1 to 17 months).All the patients had demonstrated ineffective drug therapy and 8 of them with systolic dysfunction(EF<50%).Exclusion criteria:(1)Electrocardiogram or Holter Electrocardiogram monitoring suggest impure atrial flutter and atrial fibrillation;(2)Complicated with severe valvular heart disease or previous cardiac surgery;(3)Merger of hyperthyroidism or severe COPD and other serious organic disease.Electrophysiologically examination was performed on the patient and identified as atrial tachycardia originating from pulmonary vein.According to the ablation procedure,they were divided into 3 groups,including 14 cases of focal ablation group,14 cases of single pulmonary vein isolation group,and 17 cases of circumferential pulmonary vein isolation group.Collecting surgical data for patients with different ablation strategies.Postoperative follow-up visits were performed to obtain follow-up electrocardiogram results.The follow-up time was 1,3,6,9 and 12 months after ablation and 3-6 months was performed later.Results:(1)Twenty-three patients presented with unstable peripheralatrial tachyarrhythmias,which showed warm awakening phenomenon.The activation order recorded by coronary sinus electrodes was C1,2 ahead of CS9,0 in atrial tachyarrhythmias that arising from left pulmonary vein,with eccentric conduction;While the atrial tachyarrhythmias originating from right pulmonary vein,the order of activation recorded by the coronary sinus electrodes was C9,0 leading to CS1,2 and showed centripetal conduction.(2)Ablation catheter mapping,the most advanced position of the A wave is identified as the origin,including 5 cases of right upper pulmonary vein anterior,4 cases of right upper pulmonary vein posterior,5 cases of right lower pulmonary vein anterior,6 cases of right lower pulmonary vein posterior,6 cases of left upper pulmonary vein anterior,7 cases in the left upper pulmonary vein posterior,8 cases in the left lower pulmonary vein anterior,and 4 cases in the left lower pulmonary vein posterior.All procedures were acutely successful.The target pulmonary veins were successfully isolated whether it was a single pulmonary vein isolation group or circumferential pulmonary vein isolation group.(3)The operative time of focal ablation group,single pulmonary vein isolation group,and circumferential pulmonary vein isolation group were 125.21±16.02(96-156)min,129.29±18.19(97-165)min,and 133.41±19.74(97-166)min,respectively.The circumferential pulmonary vein isolation group was longer than the other two groups in terms of operative time,but there was no statistically significant difference.The ablation time in focal ablation group,single pulmonary vein isolation group and circumferential pulmonary vein isolation group were respectively 191.64±40.90(121-262)s,603.79±162.75(345~844)s,and 1324.14±257.30(1030-1687)s,The circumferential pulmonary vein isolation group was longer than the other two groups in terms of ablation time,with statistically significant differences.X-ray exposure time in focal ablation group,single pulmonary vein isolation group and circumferential pulmonary vein isolation group were 29.07±9.56(13-41)min,20.93±8.19(13-45)min,and 25.12±6.65(12-34)min,respectively.The exposure time in the focal ablation group was significantly longer.(4)There were 3 periprocedural complications of ablation.One patient had a cardiac tamponade(circumferential pulmonary vein isolation group),one femoral aneurysm(focal ablation group),and one pneumothorax(focal ablation group).No death occurred and no severe case such as severe pericardial effusions that require of surgical repair.(5)An average of 38.69 ± 22.80 months(6-81 months)follow-up were performed after ablation.During the period,there were 4 cases atrial tachycardia recurrence,all of which recurred within 2 months.There were 3 cases in the focal group and 1 case in the single pulmonary vein isolation group.There was no recurrence in the circumferential pulmonary vein isolation group.(6)There were 6 patients developed atrial fibrillation after ablation,and 3 patients underwent atrial fibrillation ablation.Among them 4 cases in the focal ablation group and 2 cases in the single pulmonary vein isolation group,No patients developed atrial fibrillation in the circumferential pulmonary vein isolation group(p = 0.03 compared with the focal group),and with statistically significant differences.Conclusions:Radiofrequency ablation is a safety and effectively treatment for atrial tachycardia originating from pulmonary vein;pulmonary vein isolation on the basis of focal ablation for pulmonary vein atrial tachycardia significantly increases the ablation time,but does not significantly increase the risk of periprocedural complications.The isolation of pulmonary veins which atrial tachycardia originating from,especially circumferential pulmonary vein isolation may reduce the recurrence rate of atrial tachycardia;The isolation of pulmonary veins which atrial tachycardia originating from,especially circumferential pulmonary vein isolation,may reduce the development of atrial fibrillation.