How to Reach the Left Atrium in Atrial Fibrillation Ablation?

HomeCirculation: Arrhythmia and ElectrophysiologyVol. 12, No. 4How to Reach the Left Atrium in Atrial Fibrillation Ablation? Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplementary MaterialsFree AccessReview ArticlePDF/EPUBHow to Reach the Left Atrium in Atrial Fibrillation Ablation?Patent Foramen Ovale Versus Transseptal Puncture Romy Sweda, MD, Andreas Haeberlin, MD, PhD, Jens Seiler, MD, Helge Servatius, MD, Fabian Noti, MD, Anna Lam, MD, Samuel Baldinger, MD, Eleni Goulouti, MD, Argelia Medeiros-Domingo, MD, PhD, Juerg Fuhrer, MD, Tobias Reichlin, MD, Laurent Roten, MD and Hildegard Tanner, MD Romy SwedaRomy Sweda Romy Sweda, MD, Department of Cardiology, Inselspital, Bern University Hospital, Murtenstrasse 50, 3010 Bern, Switzerland, Email E-mail Address: [email protected] Department of Cardiology, Inselspital, Bern University Hospital, Switzerland (R.S., A.H., J.S., H.S., F.N., A.L., S.B., E.G., A.M.-D., J.F., T.R., L.R., H.T.). ARTORG Center for Biomedical Engineering Research, University of Bern, Switzerland (R.S., A.H.). , Andreas HaeberlinAndreas Haeberlin Department of Cardiology, Inselspital, Bern University Hospital, Switzerland (R.S., A.H., J.S., H.S., F.N., A.L., S.B., E.G., A.M.-D., J.F., T.R., L.R., H.T.). ARTORG Center for Biomedical Engineering Research, University of Bern, Switzerland (R.S., A.H.). , Jens SeilerJens Seiler Department of Cardiology, Inselspital, Bern University Hospital, Switzerland (R.S., A.H., J.S., H.S., F.N., A.L., S.B., E.G., A.M.-D., J.F., T.R., L.R., H.T.). , Helge ServatiusHelge Servatius Department of Cardiology, Inselspital, Bern University Hospital, Switzerland (R.S., A.H., J.S., H.S., F.N., A.L., S.B., E.G., A.M.-D., J.F., T.R., L.R., H.T.). , Fabian NotiFabian Noti Department of Cardiology, Inselspital, Bern University Hospital, Switzerland (R.S., A.H., J.S., H.S., F.N., A.L., S.B., E.G., A.M.-D., J.F., T.R., L.R., H.T.). , Anna LamAnna Lam Department of Cardiology, Inselspital, Bern University Hospital, Switzerland (R.S., A.H., J.S., H.S., F.N., A.L., S.B., E.G., A.M.-D., J.F., T.R., L.R., H.T.). , Samuel BaldingerSamuel Baldinger Department of Cardiology, Inselspital, Bern University Hospital, Switzerland (R.S., A.H., J.S., H.S., F.N., A.L., S.B., E.G., A.M.-D., J.F., T.R., L.R., H.T.). , Eleni GouloutiEleni Goulouti Department of Cardiology, Inselspital, Bern University Hospital, Switzerland (R.S., A.H., J.S., H.S., F.N., A.L., S.B., E.G., A.M.-D., J.F., T.R., L.R., H.T.). , Argelia Medeiros-DomingoArgelia Medeiros-Domingo Department of Cardiology, Inselspital, Bern University Hospital, Switzerland (R.S., A.H., J.S., H.S., F.N., A.L., S.B., E.G., A.M.-D., J.F., T.R., L.R., H.T.). , Juerg FuhrerJuerg Fuhrer Department of Cardiology, Inselspital, Bern University Hospital, Switzerland (R.S., A.H., J.S., H.S., F.N., A.L., S.B., E.G., A.M.-D., J.F., T.R., L.R., H.T.). , Tobias ReichlinTobias Reichlin Department of Cardiology, Inselspital, Bern University Hospital, Switzerland (R.S., A.H., J.S., H.S., F.N., A.L., S.B., E.G., A.M.-D., J.F., T.R., L.R., H.T.). , Laurent RotenLaurent Roten Department of Cardiology, Inselspital, Bern University Hospital, Switzerland (R.S., A.H., J.S., H.S., F.N., A.L., S.B., E.G., A.M.-D., J.F., T.R., L.R., H.T.). and Hildegard TannerHildegard Tanner Hildegard Tanner, MD, Department of Cardiology, Inselspital, Bern University Hospital, Freiburgstrasse, 3010 Bern, Switzerland, Email E-mail Address: [email protected] Department of Cardiology, Inselspital, Bern University Hospital, Switzerland (R.S., A.H., J.S., H.S., F.N., A.L., S.B., E.G., A.M.-D., J.F., T.R., L.R., H.T.). Originally published25 Mar 2019https://doi.org/10.1161/CIRCEP.118.006744Circulation: Arrhythmia and Electrophysiology. 2019;12:e006744About every fourth patient presenting for catheter ablation of atrial fibrillation (AF) has a persistent foramen ovale (PFO).1 This remnant of the fetal circulation can be used as route to the left atrium (LA) during AF ablation, obviating the need for a transseptal puncture (TSP) with its associated risks. However, as the location of PFOs is different from the preferred TSP site, potential downsides are difficulties in catheter positioning and suboptimal catheter support,1 which may negatively affect ablation results.To investigate the impact of the route to the LA on procedural characteristics, complications, and ablation success, we retrospectively assessed all AF ablations that were performed at our institution from January 2001 to December 2016. The study was approved by the local ethics committee, and all patients gave informed consent. Data are available from the last author on reasonable request. All procedures were grouped according to the LA access into PFO or TSP. PFOs were identified preinterventionally using transesophageal echocardiography with contrast or intraprocedurally by catheter probing. The number of attempts to use a PFO was at the discretion of the operator. TSPs were performed using a Brockenborough needle under fluoroscopy guidance; usually a single TSP was made. No intracardiac or procedural transesophageal echocardiography was used. Catheter ablations were performed as described previously,2 except that since 2012 3-dimensional mapping was used. Short-term ablation success was defined as isolation of pulmonary veins, while long-term success was defined as freedom of any atrial tachyarrhythmia >30 s after one or multiple procedures, on or off antiarrhythmic drugs at the last follow-up. Follow-ups at our clinic were performed after 3, 6, and 12 months and every year thereafter and included a continuous 7-day ECG at every visit.From 1626 AF ablations in 1055 patients, 355 were performed through a PFO, with a constant rate over the observed time period; 1081 were primary interventions, while 545 were repeat procedures. Apart from more males (83% versus 74%, P=0.001) and a higher rate of preablation strokes (11% versus 6%, P=0.006) in the PFO group, the patients did not differ in their baseline characteristics (Table I in the Data Supplement). The PFO was identified by contrast-aided transesophageal echocardiography in 95% of cases, while the rate of TSP in cases where a PFO was present according to transesophageal echocardiography was 5%. In both groups, about 52% interventions were pulmonary vein isolation only, while the remaining cases involved ablation of additional left (47%) or right (29%) atrial lines/fractionated potentials/foci (Table II in the Data Supplement).There was no difference in radiofrequency duration and power, whereas fluoroscopy times (44±32 versus 48±33 min; P=0.009), radiation doses (249±272 versus 300±491 Gy·cm2; P=0.003), and total procedural durations (179±77 versus 184±82 min; P=0.05) were shorter in trans-PFO ablations. The differences were observed in interventions involving additional ablations, not however in pulmonary vein isolation–only procedures (Table). This is in contrast to a previous report, where 49 PFO-mediated pulmonary vein isolations required longer radiofrequency application to isolate the PVs,1 but in line with another study that found similar radiofrequency durations for trans-PFO and trans-TSP mitral and roof lines.3 Whether the contrasting results are due to different techniques and the reason for the shorter procedural times in PFO-mediated ablations remain to be determined.Table. Procedural Characteristics, Complication Rates, and Success Rates in PFO Versus TSP-Mediated Atrial Fibrillation AblationsPFO (n=355)*TSP (n=1271)†P Value‡OR§95% CIProcedural characteristics, mean±SD Radiofrequency duration, min44±2343±25NS§ PVI41±2042±21NS§ PVI+47±2646±27NS§ PVI+left48±2647±27NS§ Radiofrequency power, watt·s69 527±39 43968 258±40 791NS§ PVI65 677±33 59965 855±34854NS§ PVI+74 774±44 32673 685±44 328NS§ PVI+left75 835±44 14974 332±44 609NS§ Fluoroscopy time, min44±3248±340.009§ PVI35±2936±28NS§ PVI+55±3261±340.004§ PVI+left55±3262±340.007§ Radiation dose, Gy·cm2249±272300±4910.003§ PVI184±219192±285NS§ PVI+330±308418±6240.005§ PVI+left334±309420±6250.01§ Total duration, min179±77184±820.05§ PVI167±72170±74NS§ PVI+193±79210±860.007§ PVI+left194±80210±860.01§Complication rates, n (%) All complications10 (2.8)82 (6.5)0.010.410.19–0.92 PVI7 (3.6)59 (8.9)0.020.410.18–0.91 PVI+3 (1.9)23 (3.8)NS0.460.14–1.56 PVI+left3 (1.9)23 (3.8)NS0.470.14–1.59 Tamponade3 (0.8)14 (1.1)NS0.930.26–3.31 PVI3 (1.5)11 (1.7)NS1.010.28–3.68 PVI+0 (0.0)3 (0.5)NS1.310–16.85 PVI+left0 (0.0)3 (0.5)NS1.310–16.93 Stroke/TIA2 (0.6)9 (0.7)NS0.760.16–3.56 PVI2 (1.0)6 (0.9)NS1.130.23–5.64 PVI+0 (0.0)3 (0.5)NS0.820–7.66 PVI+left0 (0.0)3 (0.5)NS0.820–7.70 Mispuncture1 (0.3)12 (0.7)NS0.830.17–3.92 PVI1 (0.5)12 (1.8)NS0.370.05–2.91 PVI+0 (0.0)0 (0.0)NANANA PVI+left0 (0.0)0 (0.0)NANANA Vascular0 (0.0)20 (1.6)0.010.140–0.83 PVI0 (0.0)13 (2.0)NS0.210–1.26 PVI+0 (0.0)7 (1.2)NS0.470–3.36 PVI+left0 (0.0)6 (1.0)NS0.620–4.72 Other4 (0.8)27 (2.1)NS0.210.03–1.60 PVI1 (0.0)17 (2.6)NS0.860.15–3.33 PVI+3 (1.9)10 (1.6)NS0.950.16–3.77 PVI+left3 (1.9)11 (1.8)NS0.950.17–3.75Success rates, n (%) FU, months (median, IQR)12 (6–25)12 (6–24)NS§ Repeat ablations per patient105 (44.3)351 (41.7)NS1.100.82–1.48 Total repeat ablations118 (33.2)427 (33.6)NS0.980.77–1.26 RSPV recurrence61 (53.5)193 (49.9)NS1.080.71–1.64 RIPV recurrence66 (60.0)185 (49.5)0.051.541.00–2.37 LSPV recurrence56 (50.0)208 (53.2)NS0.960.63–1.47 LIPV recurrence60 (55.0)184 (48.2)NS1.430.93–2.20 Roof line recurrence‖13 (54.2)38 (51.4)NS1.140.43–2.98 Mitral line recurrence#4 (40.0)10 (25.6)NS1.880.44–7.99Success rates Isolation of all PV330 (94.0)1171 (94.0)NS0.990.60–1.66 After 2012147 (97.4)530 (96.9)NS1.220.40–3.69 Overall success140 (69.0)474 (66.5)NS1.100.78–1.53 PAF108 (73.5)355 (72.9)NS1.010.67–1.54 PersAF32 (52.7)119 (57.1))NS1.090.60–2.00PVI+ includes any additional left- or right-sided fractionated potential/foci or line ablation. PVI+left includes any left atrial additional fractionated potential/foci or line ablation. FU indicates follow up; LIPV, left inferior pulmonary vein; LSPV, left superior pulmonary vein; NA, not applicable; NS, not significant; OR, odds ratio; PAF, paroxysmal atrial fibrillation; PersAF, persistent atrial fibrillation; PFO, patent foramen ovale; PV, pulmonary vein; PVI, pulmonary vein isolation; PVI+, pulmonary vein isolation plus ablation of additional lines/foci; RIPV, right inferior pulmonary vein; RSPV, right superior pulmonary vein; and TSP, transseptal puncture.*PFO (n PVI-only), 194; (n PVI+), 162; (n PVI+left), 158.†TSP (n PVI-only), 662; (n PVI+), 609; (n PVI+left), 598.‡Unadjusted using Pearson's χ2/Fisher exact test.§Adjusted for sex using linear/logistic regression.‖For patients with roof line at first ablation (PFO n=58 [16%], TSP n=217 [17%], ns).#For patients with mitral line at first ablation (PFO n=35 [10%], TSP n=137 [11%], ns).Besides these small differences in procedural characteristics, there was a significantly higher complication rate in TSP patients (5.5% versus 2.3%; odds ratio =2.41; 95% CI=1.14–5.08; Table). The difference was predominantly driven by a higher rate of vascular complications (defined as access site complications requiring an intervention), whereas the rate of tamponades and strokes/TIAs was not different between groups. We hypothesized that the higher vascular event rate might had been the result of a higher femoral sheath usage in the TSP group (P=0.026). However, adjusting for the number of femoral sheaths did not alter the result (gender- and sheath-adjusted OR for overall complications =2.24; 95% CI, 1.06–4.75). A higher rate of adverse events in TSP-mediated compared with PFO-mediated ablations has not been described previously, possibly due to a lack of power considering the small number of PFO patients in prior studies.1,3 Why especially vascular complications were higher in our TSP cohort is not clear, however, wherefore the finding should be interpreted with caution.Irrespective of complications, the mode of LA access had no effect on ablation success (Table). During repeat procedures, we observed a trend for more right inferior pulmonary vein reconnections in PFO patients (60.0% versus 49.5%; odds ratio =1.54; 95% CI, 1.00–2.37). When considering the trajectory that the PFO imposes on LA access, the finding is not surprising, as the approach makes it especially difficult to reach the right inferior pulmonary vein. Despite the higher reconnection rate, after a median follow-up of 12 months and a mean of 1.6±0.8 ablations per patient, 2 of 3 both PFO and TSP patients were free of any atrial tachyarrhythmia.Taken together, despite some novel and possibly unexpected observations in this study, the findings strengthen the evidence from prior smaller investigations1,3–5 and support the notion that using a PFO to gain access to the LA for ablation of AF is safe, efficient, and without negative impact on ablation success.DisclosuresDr Tanner has received a travel grant from Abbott. Dr Roten has received travel grants from Biosense Webster and Boston Scientific. Dr Reichlin has received speaker honoraria and travel support from Abbott, Biosense-Webster, and Medtronic. Dr Noti has received travel support and speaker honoraria from Abbott and Medtronic and a travel and educational grant from Spectranetics. Dr Baldinger has received a travel grant from LivaNova. The other authors report no conflicts.FootnotesThe Data Supplement is available at https://www.ahajournals.org/doi/suppl/10.1161/CIRCEP.118.006744.Romy Sweda, MD, Department of Cardiology, Inselspital, Bern University Hospital, Murtenstrasse 50, 3010 Bern, Switzerland, Email romy.[email protected]chHildegard Tanner, MD, Department of Cardiology, Inselspital, Bern University Hospital, Freiburgstrasse, 3010 Bern, Switzerland, Email hildegard.[email protected]chReferences1. 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Fluoroscopy-free pulmonary vein isolation in patients with atrial fibrillation and a patent foramen ovale using solely an electroanatomic mapping system.PLoS One. 2016; 11:e0148059. doi: 10.1371/journal.pone.0148059CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Barrio-Lopez M, Castellanos E, Betancur A, Zorita B, Medina J, Losada N, del Valle M, Sanchez C, Crespo R, Gonzalez V, Morales T, Urriza B, Ortiz M and Almendral J (2022) The presence of a large patent foramen ovale reduces acute and chronic success in atrial fibrillation ablation, Journal of Interventional Cardiac Electrophysiology, 10.1007/s10840-022-01134-y April 2019Vol 12, Issue 4 Advertisement Article InformationMetrics © 2019 American Heart Association, Inc.https://doi.org/10.1161/CIRCEP.118.006744PMID: 30905166 Originally publishedMarch 25, 2019 Keywordsatrial fibrillationpatent foramen ovaleatrial septumpuncturecatheter ablationPDF download Advertisement SubjectsArrhythmiasAtrial FibrillationCatheter Ablation and Implantable Cardioverter-DefibrillatorComplicationsQuality and OutcomesTreatment