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Original Articles

Spatiotemporal Organization of the Left Atrial Substrate After Circumferential Pulmonary Vein Isolation of Atrial Fibrillation

Yenn-Jiang Lin, MD; Ching-Tai Tai, MD; Tsair Kao, PhD; Shih-Lin Chang, MD; Li-Wei Lo, MD; Ta-Chuan Tuan, MD; Ameya R. Udyavar, MD; Wanwarang Wongcharoen, MD; Yu-Feng Hu, MD; Han-Wen Tso, MS; Wen-Chin Tsai, MD; Chien-Jung Chang, MD; Kuo-Chang Ueng, MD; Satoshi Higa, MD, PhD and Shih-Ann Chen, MD

From the Division of Cardiology (Y.-J.L., C.-T.T., S.-L.C., L.-W.L., T.-C.T., A.R.U., W.W., W.-C.T., C.-J.C., S.-A.C.), Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine (Y.-J.L., L.-W.L., T.-C.T., M.R.U., S.-A.C.) and Cardiovascular Research Center and Institute of Biomedical Engineering (T.K., H.-W.T.), National Yang-Ming University, Taipei, Taiwan; the Division of Cardiology (Y.-F.H.), Taipei Medical University Hospital, Taipei, Taiwan; the Division of Cardiology and Cardiovascular Surgery (K.-C.U.), Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan; and Second Department of Internal Medicine (S.H.), Faculty of Medicine, University of the Ryukyus, Okinawa, Japan.

Correspondence to Shih-Ann Chen, MD, Division of Cardiology, Taipei Veterans General Hospital, 201, Sec 2, Shih-Pai Road, Taipei, Taiwan. E-mail epsachen{at}ms41.hinet.net

Received August 4, 2008; accepted February 20, 2009.

Background— There is a paucity of data regarding the mechanism of maintaining atrial fibrillation (AF) after pulmonary vein isolation (PVI) in patients with AF. The aim of this study was to examine the impact of circumferential PVI on the left atrial (LA) substrate characteristics.

Methods and Results— Seventy-two AF patients (age, 53±11 years) underwent mapping and catheter ablation using an NavX system. The biatrial characteristics such as the complex fractionated atrial electrograms (CFEs; based on fractionated intervals) and frequency analysis (based on dominant frequencies) were mapped before and after PVI. PVI with electric isolation was performed in all patients. In the 45 patients who did not respond to PVI, the continuous CFEs (>8 seconds, 18±18% and 12±17% of the LA sites, before and after PVI, respectively, P=0.02), degree of LA fractionation (mean fractionated interval: 75.6±14.3 msec versus 87.3±16.7 msec, P=0.001), and mean LA dominant frequencies (6.92±0.88 Hz versus 6.58±0.91 Hz, P=0.001) decreased after PVI. Complete PVI altered the distribution of the CFEs toward the LA anteroseptum, mitral annulus, and LA appendage regions. A persistent presence of continuous CFEs in the vicinity of the dominant frequencies sites (observed in 53% patients) correlated with a higher procedural AF termination rate for the CFE ablation (63% versus 23%, P<0.05).

Conclusions— Complete PVI eliminated some CFEs in the LA and altered the distribution of the CFEs. The persistent presence of CFEs before and after PVI in the vicinity of the high frequency sites is important for AF maintenance after PVI.

Key Words: atrial fibrillation • electrogram frequency analysis • left atrium

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