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CLINICAL RESEARCH: HEART RHYTHM DISORDER

Atrial Tachycardia After Circumferential Pulmonary Vein Ablation of Atrial Fibrillation

Mechanistic Insights, Results of Catheter Ablation, and Risk Factors for Recurrence

Division of Cardiology, University of Michigan Hospitals, Ann Arbor, Michigan.

Manuscript received April 5, 2007; revised manuscript received June 29, 2007, accepted July 1, 2007.

^_* Reprint requests and correspondence: Dr. Aman Chugh, Cardiology, TC B1 D140, 1500 East Medical Center Drive, Ann Arbor, Michigan 48109-0311. (Email: achugh{at}umich.edu).

Objectives: The aim of this study was to determine the mechanism of atrial tachycardia (AT) that occurs after ablation of atrial fibrillation (AF).

Background: Patients who undergo catheter ablation of AF may develop AT during follow-up.

Methods: Seventy-eight patients underwent an ablation procedure for AT after circumferential pulmonary vein ablation (CPVA) for AF. The 3-dimensional maps from the AF and AT procedures were compared to determine whether AT arose from a prior ablation line.

Results: A total of 155 ATs were mapped, and the mechanism was re-entry in 137 (88%) and focal in 18 (12%). The most common left atrial (LA) ablation targets were the mitral isthmus, roof, and septum. The critical isthmus in 115 of the 120 LA re-entrant ATs (96%) traversed a prior ablation line, consistent with a gap-related mechanism. Catheter ablation was successful in 66 of the 78 patients (85%). After a mean follow-up of 13 ± 10 months, 60 of the 78 patients (77%) were free of AT/AF without antiarrhythmic medications. Re-entrant septal AT was associated with recurrence (odds ratio 7.3; 95% confidence interval 1.5 to 36; p = 0.02), whereas PV isolation during the AT procedure was associated with a favorable outcome (odds ratio 0.17; 95% confidence interval 0.04 to 0.81; p = 0.03).

Conclusions: Approximately 90% of ATs after CPVA are re-entrant, and nearly all are related to gaps in prior ablation lines. These findings suggest that the prevalence of these arrhythmias may be reduced by limiting the number of linear lesions, demonstration of linear block, and pulmonary vein disconnection during the initial AF procedure.

Abbreviations and Acronyms   AF = atrial fibrillation   AT = atrial tachycardia   CPVA = circumferential pulmonary vein ablation   CS = coronary sinus   LA = left atrium/atrial   PV = pulmonary vein

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