Acute electrical isolation is a necessary but insufficient endpoint for achieving durable PV isolation: The importance of closing the visual gap

Marc A. Miller, Andre Davila, Srinivas R. Dukkipati, Jacob S. Koruth, Juan Viles Gonzalez, Craig Napolitano, Charles Eggert, Avi Fischer, Joseph A. Gomes, Vivek Y. Reddy

Research output: Contribution to journalArticle

55 Citations (Scopus)

Abstract

Aims: Temporary, ablation-mediated effects such as oedema may cause reversible pulmonary vein (PV) isolation. To investigate this, point-by-point circumferential ablation was performed to achieve acute electrical PV isolation with an incomplete circumferential ablation line. Then, the impact of this intentional 'visual gap' (ViG) on the conduction properties of the ablation lesion set was assessed with adenosine and pacing manoeuvres. Methods and results: Twenty-eight patients undergoing ablation for paroxysmal (n = 20) or persistent atrial fibrillation (n = 8) were included. Pulmonary vein (PV) ablation was performed around ipsilateral vein pairs. Once acute isolation was achieved, ablation was halted and the presence and size of the ViG were calculated. The ViG electrophysiological properties were tested with pace capture along the ViG at 10 mA/2 ms, and assessment for dormant PV conduction with adenosine. Despite electrical isolation, a ViG was present in 75% (n = 42/56) of vein pairs (21 of 28 left PVs and 21 of 28 right PVs). There was no difference in the ViG size between the left and right PVs (22.1 ± 14.2 and 17.3 ± 11.3 mm, P > 0.05). Dormant PV connections were revealed by adenosine in more than a quarter (n = 12/42) of acutely isolated PV pairs, of which the majority were dependent on conduction through the ViG. Conclusions: Electrical PV isolation can usually be achieved without complete circumferential ablation. However, more than a quarter of these 'isolated' PVs exhibit dormant conduction-predominantly via the un-ablated 'ViGs' in the ablation lesion set. These findings support the hypothesis that reversible tissue injury contributes to PV isolation that may be acute but not necessarily durable.

Original languageEnglish
Pages (from-to)653-660
Number of pages8
JournalEuropace
Volume14
Issue number5
DOIs
StatePublished - May 1 2012
Externally publishedYes

Fingerprint

Pulmonary Veins
Adenosine
Veins
Atrial Fibrillation
Edema
Wounds and Injuries

Keywords

  • Atrial fibrillation
  • Catheter ablation
  • Dormant conduction

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Physiology (medical)

Cite this

Miller, M. A., Davila, A., Dukkipati, S. R., Koruth, J. S., Viles Gonzalez, J., Napolitano, C., ... Reddy, V. Y. (2012). Acute electrical isolation is a necessary but insufficient endpoint for achieving durable PV isolation: The importance of closing the visual gap. Europace, 14(5), 653-660. https://doi.org/10.1093/europace/eus048

Acute electrical isolation is a necessary but insufficient endpoint for achieving durable PV isolation : The importance of closing the visual gap. / Miller, Marc A.; Davila, Andre; Dukkipati, Srinivas R.; Koruth, Jacob S.; Viles Gonzalez, Juan; Napolitano, Craig; Eggert, Charles; Fischer, Avi; Gomes, Joseph A.; Reddy, Vivek Y.

In: Europace, Vol. 14, No. 5, 01.05.2012, p. 653-660.

Research output: Contribution to journalArticle

Miller, MA, Davila, A, Dukkipati, SR, Koruth, JS, Viles Gonzalez, J, Napolitano, C, Eggert, C, Fischer, A, Gomes, JA & Reddy, VY 2012, 'Acute electrical isolation is a necessary but insufficient endpoint for achieving durable PV isolation: The importance of closing the visual gap', Europace, vol. 14, no. 5, pp. 653-660. https://doi.org/10.1093/europace/eus048
Miller, Marc A. ; Davila, Andre ; Dukkipati, Srinivas R. ; Koruth, Jacob S. ; Viles Gonzalez, Juan ; Napolitano, Craig ; Eggert, Charles ; Fischer, Avi ; Gomes, Joseph A. ; Reddy, Vivek Y. / Acute electrical isolation is a necessary but insufficient endpoint for achieving durable PV isolation : The importance of closing the visual gap. In: Europace. 2012 ; Vol. 14, No. 5. pp. 653-660.
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abstract = "Aims: Temporary, ablation-mediated effects such as oedema may cause reversible pulmonary vein (PV) isolation. To investigate this, point-by-point circumferential ablation was performed to achieve acute electrical PV isolation with an incomplete circumferential ablation line. Then, the impact of this intentional 'visual gap' (ViG) on the conduction properties of the ablation lesion set was assessed with adenosine and pacing manoeuvres. Methods and results: Twenty-eight patients undergoing ablation for paroxysmal (n = 20) or persistent atrial fibrillation (n = 8) were included. Pulmonary vein (PV) ablation was performed around ipsilateral vein pairs. Once acute isolation was achieved, ablation was halted and the presence and size of the ViG were calculated. The ViG electrophysiological properties were tested with pace capture along the ViG at 10 mA/2 ms, and assessment for dormant PV conduction with adenosine. Despite electrical isolation, a ViG was present in 75{\%} (n = 42/56) of vein pairs (21 of 28 left PVs and 21 of 28 right PVs). There was no difference in the ViG size between the left and right PVs (22.1 ± 14.2 and 17.3 ± 11.3 mm, P > 0.05). Dormant PV connections were revealed by adenosine in more than a quarter (n = 12/42) of acutely isolated PV pairs, of which the majority were dependent on conduction through the ViG. Conclusions: Electrical PV isolation can usually be achieved without complete circumferential ablation. However, more than a quarter of these 'isolated' PVs exhibit dormant conduction-predominantly via the un-ablated 'ViGs' in the ablation lesion set. These findings support the hypothesis that reversible tissue injury contributes to PV isolation that may be acute but not necessarily durable.",
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T1 - Acute electrical isolation is a necessary but insufficient endpoint for achieving durable PV isolation

T2 - The importance of closing the visual gap

AU - Miller, Marc A.

AU - Davila, Andre

AU - Dukkipati, Srinivas R.

AU - Koruth, Jacob S.

AU - Viles Gonzalez, Juan

AU - Napolitano, Craig

AU - Eggert, Charles

AU - Fischer, Avi

AU - Gomes, Joseph A.

AU - Reddy, Vivek Y.

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N2 - Aims: Temporary, ablation-mediated effects such as oedema may cause reversible pulmonary vein (PV) isolation. To investigate this, point-by-point circumferential ablation was performed to achieve acute electrical PV isolation with an incomplete circumferential ablation line. Then, the impact of this intentional 'visual gap' (ViG) on the conduction properties of the ablation lesion set was assessed with adenosine and pacing manoeuvres. Methods and results: Twenty-eight patients undergoing ablation for paroxysmal (n = 20) or persistent atrial fibrillation (n = 8) were included. Pulmonary vein (PV) ablation was performed around ipsilateral vein pairs. Once acute isolation was achieved, ablation was halted and the presence and size of the ViG were calculated. The ViG electrophysiological properties were tested with pace capture along the ViG at 10 mA/2 ms, and assessment for dormant PV conduction with adenosine. Despite electrical isolation, a ViG was present in 75% (n = 42/56) of vein pairs (21 of 28 left PVs and 21 of 28 right PVs). There was no difference in the ViG size between the left and right PVs (22.1 ± 14.2 and 17.3 ± 11.3 mm, P > 0.05). Dormant PV connections were revealed by adenosine in more than a quarter (n = 12/42) of acutely isolated PV pairs, of which the majority were dependent on conduction through the ViG. Conclusions: Electrical PV isolation can usually be achieved without complete circumferential ablation. However, more than a quarter of these 'isolated' PVs exhibit dormant conduction-predominantly via the un-ablated 'ViGs' in the ablation lesion set. These findings support the hypothesis that reversible tissue injury contributes to PV isolation that may be acute but not necessarily durable.

AB - Aims: Temporary, ablation-mediated effects such as oedema may cause reversible pulmonary vein (PV) isolation. To investigate this, point-by-point circumferential ablation was performed to achieve acute electrical PV isolation with an incomplete circumferential ablation line. Then, the impact of this intentional 'visual gap' (ViG) on the conduction properties of the ablation lesion set was assessed with adenosine and pacing manoeuvres. Methods and results: Twenty-eight patients undergoing ablation for paroxysmal (n = 20) or persistent atrial fibrillation (n = 8) were included. Pulmonary vein (PV) ablation was performed around ipsilateral vein pairs. Once acute isolation was achieved, ablation was halted and the presence and size of the ViG were calculated. The ViG electrophysiological properties were tested with pace capture along the ViG at 10 mA/2 ms, and assessment for dormant PV conduction with adenosine. Despite electrical isolation, a ViG was present in 75% (n = 42/56) of vein pairs (21 of 28 left PVs and 21 of 28 right PVs). There was no difference in the ViG size between the left and right PVs (22.1 ± 14.2 and 17.3 ± 11.3 mm, P > 0.05). Dormant PV connections were revealed by adenosine in more than a quarter (n = 12/42) of acutely isolated PV pairs, of which the majority were dependent on conduction through the ViG. Conclusions: Electrical PV isolation can usually be achieved without complete circumferential ablation. However, more than a quarter of these 'isolated' PVs exhibit dormant conduction-predominantly via the un-ablated 'ViGs' in the ablation lesion set. These findings support the hypothesis that reversible tissue injury contributes to PV isolation that may be acute but not necessarily durable.

KW - Atrial fibrillation

KW - Catheter ablation

KW - Dormant conduction

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