2-STAGED BIATRIAL LINEAR AND FOCAL ABLATION TO RESTORE SINUS RHYTHM IN PATIENTS WITH REFRACTORY CHRONIC ATRIAL-FIBRILLATION - PROCEDURE EXPERIENCE AND FOLLOW-UP BEYOND 1 YEAR

Recent observations regarding the mechanisms of chronic atrial fibrill ation (CAF) plus a few encouraging clinical reports have created a par adigm shift regarding treatment strategies and the potential for resto ring normal sinus rhythm (NSR) utilizing available catheter-based abla tion techniques. The initial and late follow-up clinical experience wi th a two-staged biatrial linear and focal radiofrequency ablation (BAL F I, II) procedure to restore NSR in patients with CAF are described. Pre-BALF management included confirming drug refractoriness and optimi zing anticoagulation therapy. BALF I and II were preceded by transesop hageal echocardiography to exclude thrombus. Femoral venous catheters were placed in the left atrium and the right atrium with extensive lef t atrial mapping ablation (linear and focal) and more limited right at rial ablation. Localized electrogram recordings demonstrated rapid, lo calized, stable focal driving rotors (FDRs) in the left atrium (nine p atients) and in the right atrium (one patient). Atrial or intraatrial tachycardia (IAT) commonly recurred after BALF I. BALF II addresses th ese recurrences by repeat mapping and ablation techniques. There were no thromboembolic complications. Two patients developed pericardial ta mponade that responded to medical management. Of the 11 patients with late follow-up data, 9 have NSR, atrial function, and are no longer ex periencing CAF. Left atrial ablation lines decrease continuous electro gram activity, probably isolate portions of the atrium, and unmask FDR s. Focal and linear ablations appear helpful in transforming CAF to NS R. FDRs are commonly localized to pulmonary vein ostium, trabeculated portions of the atrium, and left atrial appendage.