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1 J KMA Continuing Education Column Catheter Ablation of Atrial Fibrillation Young Hoon Kim, MD Division of Cardiology, Korea University College of Medicine E mail : yhkmd@unitel.co.kr J Korean Med Assoc 2006; 49(9): Abstract Atiarrhythmic drugs that are currently in use are not only frequently ineffective at eliminating atrial fibrillation (AF), but also life threatening in some patients. However, the accumulating clinical experience along with the remarkable advancement in the technology has made the catheter ablation (CA) of AF more effective and safe. The application of circular mapping catheters that can identify pulmonary vein (PV) potentials (PVPs) within the PVs has allowed the effective guidance of the electrical isolation of the PVs from the left atrium (LA). The widespread utilization of 3 dimensional (D) mapping systems has facilitated the improvement of the outcomes after CA in patients with paroxysmal (PAF) and even chronic AF (CAF). Different strategies that are currently in use are as follows segmental ablation of each PV ostium guided by PVPs, pure anatomic approach of circumferential PV ablation (CPVA), CPVA with electrical isolation, complex fractionated atrial electrograms during AF guided ablation, and ablation of ganglionated plexuses, etc. The efficacy of each approach varies according to the investigators and subsets of AF. CPVA with electrical isolation is known to be more effective and is widely used. With further development of new energy sources of ablation and mapping systems, it is important to simplify, standardize, and shorten the procedures, which may enable the CA to become more effective, safe, and applicable to many different subsets of AF. CA of AF has evolved rapidly and has become accepted as one of the therapeutic modalities to cure AF. Keywords : Atrial fibrillation /atrial arrhythmias; Catheter ablation of atrial fibrillation; Cardiac mapping 3 dimensional systems; Activation mapping of arrhythmias 837

2 Kim YH Before After PVP: pulmonary vein potential, RSPV: right superior pulmonary vein, LAO: left anterior oblique Pulmonary vein isolation confirmed by elimination of PVPs (*) 838

3 Catheter Ablation of Atrial Fibrillation 839

Kim YH A B A) 3 Dimensional Mapping System Guided Circumferential Pulmonary Vein Ablation B) Elimination of PVPs by Additional Ablation at the LA PVJunction Showing PVPs After encircling of pulmonary

4 Kim YH A B A) 3 Dimensional Mapping System Guided Circumferential Pulmonary Vein Ablation B) Elimination of PVPs by Additional Ablation at the LA PVJunction Showing PVPs After encircling of pulmonary veins (white circles in panel A), additional radiofrequency energy was delivered at the LA PV junction (dark circles in panel A) to eliminate PVPs (*) as shown in panel B). LSPV: left superior pulmonary vein, LIPV: left inferior pulmonary vein, RSPV: right superior pulmonary vein, RIPV: right inferior pulmonary vein, LA PV: left atrium pulmonary vein, PVP: pulmonary vein potential Circumferential pulmonary vein ablation with isolation 840

5 Catheter Ablation of Atrial Fibrillation 841

6 Kim YH PVA: pulmonary vein ablation. n indicates the accumulated number of patients Recurrence rate of atrial fibrillation after catheter ablation in Korea University Medical Center 842

7 Catheter Ablation of Atrial Fibrillation 1. Wyse DG, Waldo AL, DiMarco JP, Domanski MJ, Rosenberg Y, Corley SD, et al. Atrial Fibrillation Follow up Investigation of Rhythm Management (AFFIRM) Investigators. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med 2002; 347: Haissaguerre M, Jais P, Shah DC, Takahashi A, Hocini M, Clementy J, et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med 1998; 339:

8 Kim YH 3.,,,,,. Initiation and maintenance mechanism of atrial fibrillation assessed by 3 dimensional non contact mapping system. Korean Circulation J 2004; 34: Kim, Y H, Rha SW, Park SW, Park SM, Pak HN, Ro YM, et al. Wave frnt dynamics during atrial fibrillation with repetitive pulmonary vein tachycardia. Pacing Clin Electrophysiol 2003; 26: 1006(309) 5. Haissaguerre M, Jais P, Shah DC, Garrigue S, Takahashi A, Clementy J, et al. Electrophysiological end point for catheter ablation of atrial fibrillation initiated from multiple pulmonary venous foci. Circulation 2000; 101: Marrouche NF, Dresing T, Cole C, Bash D, Saad E, Natale A, et al. Circular mapping and ablation of the pulmonary vein for treatment of atrial fibrillation: impact of different catheter technologies. J Am Coll Cardiol 2002; 40: Oral H, Knight BP, Tada H, Ozaydin M, Chugh A, Morady F, et al. Pulmonary vein isolation for paroxysmal and persistent atrial fibrillation. Circulation 2002; 105: Lau CP, Tse HF, Ayers GM. Defibrillation guided radiofrequency ablation of atrial fibrillation secondary to an atrial focus. J Am Coll Cardiol 1999; 33: Pappone C, Oreto G, Rosanio S, Vicedomini G, Tocchi M, Alfieri O, et al. Atrial electroanatomic remodeling after circumferential radiofrequency pulmonary vein ablation: efficacy of an anatomic approach in a large cohort of patients with atrial fibrillation. Circulation 2001; 104: Oral H, Scharf C, Chugh A, Hall B, Cheung P, Morady F, et al. Catheter ablation for paroxysmal atrial fibrillation: segmental pulmonary vein ostial ablation versus left atrial ablation. Circulation 2003; 108: Kottkamp H, Tanner H, Kobza R, Schirdewahn P, Dorszewski A, Hindricks G. et al. Time courses and quantitative analysis of atrial fibrillation episode number and duration after circular plus linear left atrial lesions: trigger elimination or substrate modification: early or delayed cure? J Am Coll Cardiol 2004; 44: Vasamreddy CR, Dalal D, Eldadah Z, Dickfeld T, Jayam VK, Calkins H, et al. Safety and efficacy of circumferential pulmonary vein catheter ablation of atrial fibrillation. Heart Rhythm 2005; 2: Ouyang F, Bansch D, Ernst S, Schaumann A, Hachiya H, Kuck KH. Complete isolation of left atrium surrounding the pulmonary veins: new insights from the double Lasso technique in paroxysmal atrial fibrillation. Circulation 2004; 110: Nademanee K, McKenzie J, Kosar E, Schwab M, Sunsaneewitayakul B, Ngarmukos T, et al. A new approach for catheter ablation of atrial fibrillation: mapping of the electrophysiologic substrate. J Am Coll Cardiol 2004; 43: Nakagawa H, Scherlag BJ, Wu R, Po S, Lockwood D, Jackman WM, et al. Addition of selective ablation of autonomic ganglia to pulmonary vein antrum isolation for treatment of paroxysmal and persistent atrial fibrillation. Circulation 2004; 110: III Scherlag BJ, Nakagawa H, Jackman WM, Yamanashi WS, Patterson E, Lazzara R, et al. Electrical stimulation to identify neural elements on the heart: their role in atrial fibrillation. J Interv Card Electrophysiol 2005; 13: Scherlag BJ, Yamanashi WS, Schauerte P, Scherlag M, Sun YX, Lazzara R, et al. Endovascular stimulation within the left pulmonary artery to induce slowing of heart rate and paroxys- 844

9 Catheter Ablation of Atrial Fibrillation mal atrial fibrillation. Cardiovasc Res 2002; 54: Wazni OM, Marrouche NF, Martin DO, Verma A, Bhargava M, Natale A, et al. Radiofrequency ablation vs antiarrhythmic drugs as first line treatment of symptomatic atrial fibrillation. JAMA 2005; 293: Hsu LF, Jais P, Sanders P, Garrigue S, Hocini M, Haissaguerre M. Catheter ablation for atrial fibrillation in congestive heart failure. N Engl J Med 2004; 351: Hocini M, Sanders P, Deisenhofer I, Jais P, Hsu LF, Haissaguerre M. Reverse remodeling of sinus node function after catheter ablation of atrial fibrillation in patients with prolonged sinus pauses. Circulation 2003; 108: Peer Reviewer Commentary 845

특집-김영훈

특집-김영훈 Focused Issue of This Month Drug Therapy and Catheter Ablation for Atrial Fibrillation Young Hoon Kim, MD. Division of Cardiology, Korea University College of Medicine Email : yhkmd@korea.ac.kr J Korean