Pulmonary vein atrial tachycardia: do we really need to isolate or freeze?
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EDITOR’S FORUM
Pulmonary vein atrial tachycardia: do we really need to isolate or freeze? Catherine O’Shea 1
&
Dennis H. Lau 1 & Peter M. Kistler 2 & Jonathan M. Kalman 3,4 & Prashanthan Sanders 1
Received: 12 April 2019 / Accepted: 8 May 2020 # Springer Science+Business Media, LLC, part of Springer Nature 2020
Focal atrial tachycardias (ATs) have been demonstrated to arise from several anatomic sites in both atria and annexing structures that can be accurately predicted by established P wave morphology algorithms with high sensitivity and specificity [1–9]. Pulmonary vein (PV) ATs account for the majority of left-sided focal ATs with a propensity for the ostium of a single PV, especially the superior PVs [6, 10, 11]. Patients with focal PV ATs are distinct to those with atrial fibrillation (AF) as they are usually younger, with normal sized left atria and paucity of traditional AF risk factors [7, 12]. The arrhythmic mechanism underlying PV ATs is understood to be due to triggered activity or abnormal automaticity whereby the tachycardia cycle length is usually longer than those with AF, who have diffuse atrial remodelling and a spectrum of other re-entrant arrhythmias [7, 13]. Further, in those with AF, the tachycardia foci are often seen in multiple PVs and deeper into the veins, warranting isolation of all four PVs [7]. By contrast, focal ablation strategy in patients with PV ATs has demonstrated excellent long-term success rates with no AF seen at more than 7 years of follow-up [14]. Alternative ablation approach of targeted pulmonary vein isolation (PVI) has also been performed, with a small retrospective series (n = 26 patients) demonstrating potential superiority to focal ablation [10]. However, in the absence of prospective randomised
* Catherine O’Shea [email protected] 1
Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, SA 5000, Australia
2
Department of Cardiology, Alfred Hospital and the Baker IDI, Melbourne, Australia
3
Department of Cardiology, Royal Melbourne Hospital, Parkville, Australia
4
Department of Medicine, University of Melbourne, Melbourne, Australia
data, the work by Wei and co-workers in this issue of the Journal represents a welcome addition to the literature. [15] In Wei et al.’s single-centre retrospective series of 83 consecutive patients with focal PV ATs, 60 patients (72%) had ATs arising from a superior PV and 74 patients (89%) had an ostial PV focus, in keeping with previous series [7, 10, 11]. Despite this, only 35 patients underwent focal radiofrequency (RF) ablation while the remaining 48 patients underwent either PVI via wide area circumferential RF ablation (n = 25) or the cryoballoon (Arctic Front Advance, Medtronic, Minneapolis, MN, USA; n = 23). Over a mean follow-up of more than 5 years, there were no significant differences between the RF and cryoballoon ablation groups in acute procedural success, procedural complications (none in either group), or long-term AT recurrence. Similarly, there were
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