Key result
Mechanism-driven PV ablation targeting specific substrates may effectively treat PAF without requiring complete isolation.
Why the study?
Incomplete pulmonary vein isolation is curative in some paroxysmal AF patients, suggesting antiarrhythmic mechanisms other than complete electrical isolation play a role.
The authors hypothesize that incomplete pulmonary vein isolation can be curative in a subset of paroxysmal AF patients by modifying the arrhythmogenic substrate, challenging the necessity of complete electrical isolation in all cases.
May support targeted substrate ablation without complete isolation in select paroxysmal AF; leaves open need for randomized trials before practice change.
Atrial fibrillation (AF) often requires invasive treatment by ablation to decrease symptom burden. The pulmonary veins (PV) are thought to trigger paroxysms of AF, and ablative PV isolation (PVI) is a cornerstone in AF treatment. However, incomplete PVI, where electrical conduction between the PV and left atrium (LA) is maintained, is curative of AF in a subset of patients. This implies that an antiarrhythmic effect other than electrical isolation between the PV and LA plays a role in AF prevention in these patients. We reason that the PV myocardium constitutes an arrhythmogenic substrate conducive to reentry in the patients with curative incomplete PVI. This PV substrate is amenable to ablation, even when conduction between the LA and PV persists. We propose that PV ablation strategies are differentiated to fit the arrhythmogenic mechanisms in the individual patient. PV substrate modification in patients with PV reentry may constitute a new therapeutic approach that is potentially simpler and more effective, in this subgroup of patients.
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Gottlieb et al. (2023) conducted a review in Paroxysmal atrial fibrillation. Mechanism-dependent pulmonary vein ablation vs. Standard complete pulmonary vein isolation was evaluated. Mechanism-driven pulmonary vein ablation targeting specific arrhythmogenic substrates, such as reentry, may provide effective personalized treatment for paroxysmal atrial fibrillation without requiring complete isolation.
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