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Left Atrial Ablation Versus Biatrial Ablation for Persistent and Permanent Atrial Fibrillation

A Prospective and Randomized Study

Leonardo Calò, MD, FESC^_*,_*, Filippo Lamberti, MD, Maria Luisa Loricchio, MD, Ermenegildo De Ruvo, MD^_*, Furio Colivicchi, MD, FESC, Leopoldo Bianconi, MD, Claudio Pandozi, MD, FESC and Massimo Santini, MD, FESC, FACC

^_* Division of Cardiology, Policlinico Casilino, ASL RM B, Rome, Italy
Division of Cardiology, Sant’Eugenio Hospital, Rome, Italy
Department of Cardiac Diseases, Sandro Pertini Hospital, Rome, Italy
Department of Cardiac Diseases, San Filippo Neri Hospital, Rome, Italy.

View larger version (89K): [in a new window]   Figure 1 Intended line designs: anteroposterior of a mesh graph of the electroanatomic reconstruction of the right and the left atrium. Multiple dark red dots represent ablation lines. The following lesions were performed in the right atrium: (A) the isthmus line between the tricuspid annulus and the inferior vena cava. (B) The posterior intercaval line. (C) The septal line that begins from the superior vena cava, proceeds to the fossa ovalis, and to the coronary sinus ostium where a circumferential line was performed, and terminates in the inferior vena cava. In the left atrium, a circumferential lesion was placed around the left and right pulmonary veins. In addition, a linear lesion connecting the left circular lesion with the mitral annulus was placed (D). LAO = left anterior oblique.

View larger version (40K): [in a new window]   Figure 2 Examples of termination of atrial fibrillation during radiofrequency (RF) application in two patients (A and B) with permanent atrial fibrillation. Both patients had failure of electric cardioversion. Note that the atrial fibrillation termination occurred in both patients during right atrial ablation (septal line) after progressive prolongation of cycle length of FF intervals. ABL D = distal ablation catheter; ABL P = proximal ablation catheter; CS = coronary sinus; DCS = distal coronary sinus; PCS = proximal coronary sinus; RVA = right ventricular apex.

View larger version (80K): [in a new window]   Figure 3 Voltage maps of the right (A) and left atrium (B) before ablation (top) and after ablation (bottom) (posteroanterior view). Red represents lowest voltage and blue and purple, highest voltage. Multiple dark red dots represent ablation lines. Pink dots represent area of complex fractionated electrograms. Electrograms recorded from distal electrode pairs (upper tracing) and proximal electrode pairs (bottom tracing) of ablation catheter in different areas of the right and left atrium are also shown.

View larger version (26K): [in a new window]   Figure 4 Kaplan-Meier estimate of survival free of atrial fibrillation after biatrial ablation (solid line) and left atrial ablation (dotted line).