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Original Articles

Chronic Atrial Fibrillation Is a Biatrial Arrhythmia

Data from Catheter Ablation of Chronic Atrial Fibrillation Aiming Arrhythmia Termination Using a Sequential Ablation Approach

Thomas Rostock, MD; Daniel Steven, MD; Boris Hoffmann, MD; Helge Servatius, MD; Imke Drewitz, MD; Karsten Sydow, MD; Kai Müllerleile, MD; Rodolfo Ventura, MD; Karl Wegscheider, PhD; Thomas Meinertz, MD and Stephan Willems, MD

From the Departments of Cardiology (T.R., D.S., B.H., H.S., I.D., K.S., K.M., R.V., T.M., S.W.), and Medical Biometry and Epidemiology (K.W.), University Hospital Eppendorf, Hamburg, Germany.

Correspondence to Thomas Rostock, MD, Department of Cardiology, University Hospital Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany. E-mail rostock{at}uke.uni-hamburg.de

Received February 11, 2008; accepted September 15, 2008.

Background— Termination of chronic atrial fibrillation (CAF) can be achieved by catheter ablation using a stepwise approach. However, there are limited data on the contribution of the right atrium to the CAF process. Furthermore, the prognostic value of CAF termination remains unclear.

Methods and Results— Eighty-eight patients (61±10 years of age) underwent de novo ablation of CAF in 2006 at our institution. The ablation procedure was performed sequentially in the following order: pulmonary vein isolation, defragmentation of the left atrium, coronary sinus, and right atrium. Attempted procedural end point was termination of CAF. Consecutive arrhythmias occurring after AF termination were mapped, and ablation was attempted. AF termination was achieved in 68 (77%) patients: in 37 (55%) patients it occurred in the left atrium, in 18 (26%) patients in the right atrium, and in 13 (19%) patients in the coronary sinus. In 54 patients, at least one redo was performed (total number of procedures: 154). After the first redo, another 30 patients were in sinus rhythm (total 63), 8 patients were in atrial tachycardia (AT), and 17 patients were in AF. Another 11 patients underwent a second redo. After a mean follow-up of 20±4 months, 71 (81%) patients were in sinus rhythm, 1 (1%) patient was in AT, and 16 (18%) patients were in AF. Patients with CAF termination had predominantly ATs as recurrent arrhythmias (83%), whereas those without mainly presented with recurrent CAF (85%). The overall success rate in patients with CAF termination was 95% compared with 5% of patients without CAF termination in 2 procedures (n=12). In almost all redo procedures attributable to AT, at least 1 AT during redo was documented previously.

Conclusions— AF termination is a prognostic important end point of catheter ablation for CAF. Termination of AF was achieved in both atria and the coronary sinus, suggesting a biatrial substrate of CAF. Subsequent arrhythmias often recur during follow-up and, therefore, should be targeted for ablation.

Key Words: ablation • catheter ablation • atrial fibrillation • atrial tachycardia • mechanisms

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CLINICAL PERSPECTIVE

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