title: Atrial Electroanatomic Remodeling After Circumferential Radiofrequency Pulmonary Vein Ablation: Efficacy of an Anatomic Approach in a Large Cohort of Patients With Atrial Fibrillation The difference in autonomic denervation and its effect on atrial fibrillation recurrence between the standard segmental and circumferential pulmonary vein isolation techniques. Small or Large Isolation Areas Around the Pulmonary Veins for the Treatment of Atrial Fibrillation?: Results From a Prospective Randomized Study Circumferential Radiofrequency Ablation of Pulmonary Vein Ostia: A New Anatomic Approach for Curing Atrial Fibrillation Distinctive Electrophysiological Properties of Pulmonary Veins in Patients With Atrial Fibrillation Catheter Ablation for Paroxysmal Atrial Fibrillation: Segmental Pulmonary Vein Ostial Ablation Versus Left Atrial Ablation Is circumferential pulmonary vein isolation preferable to stepwise segmental pulmonary vein isolation for patients with paroxysmal atrial fibrillation? Selective segmental ostial ablation and circumferential pulmonary veins ablation. Results of an individualized strategy to cure refractory atrial fibrillation Spatiotemporal periodicity during atrial fibrillation in the isolated sheep heart. Circumferential Pulmonary Vein Ablation With Additional Linear Ablation Results in an Increased Incidence of Left Atrial Flutter Compared With Segmental Pulmonary Vein Isolation as an Initial Approach to Ablation of Paroxysmal Atrial Fibrillation Freedom From Atrial Tachyarrhythmias After Catheter Ablation of Atrial Fibrillation: A Randomized Comparison Between 2 Current Ablation Strategies Segmental pulmonary vein antrum isolation using the "large-size" lasso catheter in patients with atrial fibrillation. Electrophysiologic and anatomic characterization of sites resistant to electrical isolation during circumferential pulmonary vein ablation for atrial fibrillation: a prospective study. Mechanisms of recurrent atrial fibrillation: comparisons between segmental ostial versus circumferential pulmonary vein isolation. Left Atrial Posterior Wall Isolation Does Not Improve the Outcome of Circumferential Pulmonary Vein Ablation for Atrial Fibrillation: A Prospective Randomized Study Noninvasive Assessment of Atrial Substrate Change after Wide Area Circumferential Ablation: A Comparison with Segmental Pulmonary Vein Isolation Achievement of pulmonary vein isolation in patients undergoing circumferential pulmonary vein ablation: a randomized comparison between two different isolation approaches. Single-Ring Posterior Left Atrial (Box) Isolation Results in a Different Mode of Recurrence Compared With Wide Antral Pulmonary Vein Isolation on Long-Term Follow-Up: Longer Atrial Fibrillation–Free Survival Time but Similar Survival Time Free of Any Atrial Arrhythmia Efficacy and late recurrences with wide electrical pulmonary vein isolation for persistent and permanent atrial fibrillation. Recurrence of pulmonary vein conduction and atrial fibrillation after pulmonary vein isolation for atrial fibrillation: a randomized trial of the ostial versus the extraostial ablation strategy. Efficacy and safety of segmental ostial versus circumferential extra-ostial pulmonary vein isolation for atrial fibrillation.
abstract: Background —Circumferential radiofrequency ablation around pulmonary vein ( PV ) ostia has recently been described as a new anatomic approach for atrial fibrillation ( AF ) . Methods and Results —We treated 251 consecutive patients with paroxysmal ( n=179 ) or permanent ( n=72 ) AF .  Circular PV lesions were deployed transseptally during sinus rhythm ( n=124 ) or AF ( n=127 ) using 3D electroanatomic guidance . Procedures lasted 148±26 minutes . Among 980 lesions surrounding individual PVs ( n=956 ) or 2 ipsilateral veins with close openings or common ostium ( n=24 ) , 75 % were defined as complete by a bipolar electrogram amplitude < 0.1 mV inside the lesion and a delay > 30 ms across the line . The amount of low-voltage encircled area was 3594±449 mm2 , which accounted for 23±9 % of the total left atrial ( LA ) map surface . Major complications ( cardiac tamponade ) occurred in 2 patients ( 0.8 % ) . No PV stenoses were detected by transesophageal echocardiography . After 10.4±4.5 months , 152 patients with paroxysmal AF ( 85 % ) and 49 with permanent AF ( 68 % ) were AF-free . Patients with and without AF recurrence did not differ in age , AF duration , prevalence of heart disease , or ejection fraction , but the LA diameter was significantly higher ( P < 0.001 ) in permanent AF patients with recurrence . The proportion of PVs with complete lesions was similar between patients with and without recurrence , but the latter had larger low-voltage encircled areas after radiofrequency ( expressed as percent of LA surface area;P < 0.001 ) . Conclusions —Circumferential PV ablation is a safe and effective treatment for AF . Its success is likely due to both PV trigger isolation and electroanatomic remodeling of the area encompassing the PV ostia AIMS This study examined the difference in autonomic modification ( AM ) and its effect on paroxysmal atrial fibrillation ( PAF ) recurrence between segmental pulmonary vein isolation ( S-PVI ) and circumferential PVI ( C-PVI ) . METHODS AND RESULTS Successful S-PVI or C-PVI with a basket catheter was achieved in 120 consecutive PAF patients . Serial 24 Holter-recordings were obtained before , immediately , and 1 , 3 , 6 , 12 months after the PVI to analyse the heart rate variability ( HRV ) .  Nineteen patients were excluded from analysis because of additional ablation for recurrent PAF after successful PVI . Among the residual 101 patients , 33 had PAF recurrences ( S-PVI = 44.0 % , C-PVI = 21.6 % ) at 1 year of follow-up . The root mean square of successive differences and high-frequency power reflecting parasympathetic nervous activity were significantly lower in patients with and without PAF recurrences after C-PVI and patients without PAF recurrences after S-PVI than patients with PAF recurrences after S-PVI ( P < 0.005 - 0.0001 ) . However , there were no significant differences in any HRV parameters in the immediate aftermath of PVI among the patients without PAF recurrences after S-PVI and those with and without PAF recurrences after C-PVI . CONCLUSION Although additional radiofrequency ablation for AM may be recommended after S-PVI to reduce PAF recurrences , it should be carefully determined after C-PVI Background — Pulmonary vein ( PV ) isolation is a promising new treatment for  atrial fibrillation ( AF ) . We hypothesized that isolation of large areas around both ipsilateral PVs with verification of conduction block is more effective than the isolation of each individual PV . Methods and Results — A total of 110 patients , 67 with paroxysmal AF and 43 with persistent AF , were r and omly assigned to undergo either isolation of each individual PV or isolation of large areas around both ipsilateral PVs . The isolation of each individual PV was an electrophysiologically guided , ostial segmental ablation with a 64-pole basket catheter or a 20-pole circular mapping catheter ( group I ) . Isolation of large areas was performed around the 2 ipsilateral veins with a nonfluoroscopic navigation system and a circular 20-pole mapping catheter for verification of conduction block ( group II ) . In both groups , an irrigated-tip ablation catheter ( 25 to 35 W ) was used to achieve complete isolation . Procedure and ablation times were longer in group II , whereas fluoroscopic time was significantly shorter ( P≤0.001 ) . After a follow-up period of 15±4 months , 27 patients in group I ( 49 % ) and 37 patients in group II ( 67 % ) remained free of symptoms of AF and had no AF or atrial flutter during repetitive Holter monitoring without antiarrhythmic drug treatment after a single procedure ( P≤0.05 ) . Conclusions — The rate of success was significantly higher and fluoroscopy times were significantly lower in the group with large isolation areas around both ipsilateral PVs than in those who underwent individual PV isolation Background —The pulmonary veins ( PVs ) and surrounding ostial areas frequently house focal triggers or reentrant circuits critical to the genesis of atrial fibrillation ( AF ) . We developed an anatomic approach aim ed at isolating each PV from the left atrium ( LA ) by circumferential radiofrequency ( RF ) lesions around their ostia . Methods and Results —We selected 26 patients with resistant AF , either paroxysmal ( n=14 ) or permanent ( n=12 ) . A nonfluoroscopic mapping system was used to generate 3D electroanatomic LA maps and deliver RF energy . Two maps were acquired during coronary sinus and right atrial pacing to vali date the lateral and septal PV lesions , respectively . Patients were followed up closely for ≥6 months . Procedures lasted 290±58 minutes , including 80±22 minutes for acquisition of all maps , and 118±16 RF pulses were deployed . Among 14 patients in AF at the beginning of the procedure , 64 % had sinus rhythm restoration during ablation . PV isolation was demonstrated in 76 % of 104 PVs treated by low peak-to-peak electrogram amplitude ( 0.08±0.02 mV ) inside the circular line and by disparity in activation times ( 58±11 ms ) across the lesion . After 9±3 months , 22 patients ( 85 % ) were AF-free , including 62 % not taking and 23 % taking antiarrhythmic drugs , with no difference ( P = NS ) between paroxysmal and permanent AF . No thromboembolic events or PV stenoses were observed by transesophageal echocardiography . Conclusions —Radiofrequency PV isolation with electroanatomic guidance is safe and effective in either paroxysmal or permanent AF Background —Atrial fibrillation ( AF ) is frequently initiated from pulmonary veins ( PVs ) , but little is known of the electrophysiological properties of PVs . Methods and Results —Two groups were studied : 28 patients ( 49±13 years old ) with paroxysmal AF and 20 control patients ( 49±14 years old ) without AF . Effective and functional refractory period and conduction time from PV to left atrium ( LA ) were compared in the 2 groups by use of programmed stimulation with a single extrastimulus in the PVs and LA . In the AF group , the venous effective refractory periods ( ERPs ) were shorter than that of the LA : 185±71 versus 253±21 ms , P < 0.001 , whereas in the control group , they were longer ( 282±45 versus 253±41 ms , P = 0.009 ) . The venous ERPs and functional refractory periods in patients with AF were also shorter than that observed in control subjects ( 185±71 versus 282±45 ms and 210±77 versus 315±43 ms , respectively , P < 0.001 ) , whereas LA ERPs were not significantly different . Decremental conduction in PVs was more frequent ( 93 % versus 56 % , P = 0.01 ) and had a greater increment ( 102±65 versus 42±40 ms , P < 0.001 ) in patients with AF . Finally , AF was more frequently induced when pacing was performed in PVs ( 22 of 90 ) versus LA ( 1 of 81 ) in patients with AF ( P < 0.001 ) . Conclusions —The PVs of patients with AF exhibited distinctive electrophysiological properties , which were strikingly different from those of patients devoid of AF , potentially explaining their arrhythmogenicity Background —Segmental ostial catheter ablation ( SOCA ) to isolate the pulmonary veins ( PVs ) and left atrial catheter ablation ( LACA ) to encircle the PVs both may eliminate paroxysmal atrial fibrillation ( PAF ) .  The relative efficacy of these 2 techniques has not been directly compared . Methods and Results —Of 80 consecutive patients with symptomatic PAF ( age , 52±10 years ) , 40 patients underwent  PV isolation by SOCA and 40 patients underwent LACA to encircle the PVs . During SOCA , ostial PV potentials recorded with a ring catheter were targeted . LACA was performed by encircling the left- and right-sided PVs 1 to 2 cm from the ostia and was guided by an electroanatomic mapping system ; ablation lines also were created in the mitral isthmus and posterior left atrium . The mean procedure and fluoroscopy times were 156±45 and 50±17 minutes for SOCA and 149±33 and 39±12 minutes for LACA , respectively . At 6 months , 67 % of patients who underwent SOCA and 88 % of patients who underwent LACA  were free of symptomatic PAF when not taking antiarrhythmic drug therapy ( P = 0.02 ) . Among the variables of age , sex , duration and frequency of PAF , ejection fraction , left atrial size , structural heart disease , and the ablation technique , only an increased left atrial size and the SOCA  technique were independent predictors of recurrent PAF . The only complication was left atrial flutter in a patient who underwent LACA . Conclusions —In patients undergoing catheter ablation for PAF  , LACA to encircle the PVs is more effective than SOCA BACKGROUND Stepwise segmental pulmonary vein isolation ( SPVI ) and circumferential pulmonary vein isolation ( CPVI ) have been developed to treat patients with atrial fibrillation ( AF ) , but the preferable approach for paroxysmal AF ( PAF ) has not been established . METHODS AND RESULTS One hundred and ten patients with symptomatic PAF were r and omized into a stepwise SPVI group ( n=55 ) or CPVI group ( n=55 ) . Systemic SPVI combined with left atrial linear ablation tailored by inducibility of AF was performed in the stepwise SPVI group . Circumferential linear ablation around the left and right-sided pulmonary veins ( PVs ) guided by 3-dimensional electroanatomic mapping was performed in the CPVI group . The endpoints of ablation are non-induciblity of AF in the stepwise SPVI group and continuity of circular lesions combined with PV isolation in the CPVI group . After the initial procedures , atrial tachyarrhythmis ( ATa ) recurred within the first 3 months in 23 of the 55 patients ( 41.8 % ) who underwent stepwise SPVI and in 20 of the 55 patients ( 36.4 % ) who had CPVI ( p=0.69 ) . Repeat procedures were performed in 7 patients from the stepwise SPVI group and 5 from the CPVI group ( p=0.76 ) . During the 3 - 9 months after the last procedure , 46 patients ( 83.6 % ) from the CPVI group and 43 ( 78.2 % ) from the stepwise SPVI group did not have symptomatic ATa while not taking anti-arrhythmic drugs ( p=0.63 ) . Severe subcutaneous hematoma or PV stenosis occurred in 3 patients . CONCLUSIONS The efficacy of stepwise SPVI is comparable to that of CPVI for patients with PAF Aims Previous studies have analyzed the efficacy of atrial fibrillation (  AF )  ablation in series of consecutive patients or comparing methods in a r and omized way , without taking account individual patient characteristics . The purpose of this study was to evaluate the results of a strategy based on selecting the ablation method according to patient clinical features in drug-refractory paroxysmal or persistent AF . Methods and results Patients with left atrial diameter ≤40 mm and runs of atrial tachycardia of more than ten beats during Holter recording were selected for selective segmental ostial ablation ( SSOA ) in order to disconnect only those pulmonary veins with electrical potentials . The remaining patients underwent circumferential pulmonary veins ablation ( CPVA ) to modify left atrial substrate by extensive linear lesions . A group of 131 consecutive patients were included . Mean follow-up was 21.5 ± 15.2 months . In paroxysmal AF , 44 and 55 patients were selected for SSOA and CPVA , respectively , and the efficacy of the procedure was similar in the two groups ( 77 vs 74 % ; log-rank test p = NS ) . In persistent AF , 6 and 26 patients underwent SSOA and CPVA , respectively , and greater efficacy was observed in the second group ( 17 vs 65 % ; log-rank test p = 0.004 ) . Conclusions Selecting the ablation method according to patient characteristics achieved good results and reduced the overall amount of ablated atrial tissue in patients with paroxysmal AF . However , in persistent AF the SSOA technique showed very limited efficacy despite the previous patient selection and a CPVA-like procedure may be the appropriate choice in all cases BACKGROUND The activation patterns that underlie the irregular electrical activity during atrial fibrillation ( AF ) have traditionally been described as disorganized or r and om . Recent studies , based predominantly on statistical methods , have provided evidence that AF is spatially organized . The objective of this study was to demonstrate the presence of spatial and temporal periodicity during AF . METHODS AND RESULTS We used a combination of high-resolution video imaging , ECG recordings , and spectral analysis to identify sequential wave fronts with temporal periodicity and similar spatial patterns of propagation during 20 episodes of AF in 6 Langendorff-perfused sheep hearts . Spectral analysis of AF demonstrated multiple narrow-b and peaks with a single dominant peak in all cases ( mean , 9.4+/-2.6 Hz ; cycle length , 112+/-26 ms ) . Evidence of spatiotemporal periodicity was found in 12 of 20 optical recordings of the right atrium ( RA ) and in all ( n=19 ) recordings of the left atrium ( LA ) . The cycle length of spatiotemporal periodic waves correlated with the dominant frequency of their respective optical pseudo-ECGs ( LA : R2=0.99 , slope=0.94 [ 95 % CI , 0.88 to 0.99 ] ; RA : R2=0.97 , slope=0.92 [ 95 % CI , 0.80 to 1.03 ] ) . The dominant frequency of the LA pseudo-ECG alone correlated with the global bipolar atrial EG ( R2=0.76 , slope=0.75 [ 95 % CI , 0.52 to 0.99 ] ) . In specific examples , sources of periodic activity were seen as rotors in the epicardial sheet or as periodic breakthroughs that most likely represented transmural pectinate muscle reentry . However , in the majority of cases , periodic waves were seen to enter the mapping area from the edge of the field of view . CONCLUSIONS Reentry in anatomically or functionally determined circuits forms the basis of spatiotemporal periodic activity during AF . The cycle length of sources in the LA determines the dominant peak in the frequency spectra in this experimental model of AF Background —There has been growing concern that linear ablation is associated with an increased risk of iatrogenic arrhythmias in patients undergoing ablation for atrial fibrillation ( AF ) . Therefore , we compared circumferential pulmonary vein ablation plus left atrial linear ablation ( CPVA+LALA ) with segmental pulmonary vein isolation (PVI)in  patients with paroxysmal AF . Methods and Results —Sixty-six consecutive patients with paroxysmal AF were prospect ively r and omly assigned to receive PVI versus CPVA+LALA ( consisting of encircling lesions around the pulmonary veins ) , a roof line , and a mitral isthmus line with documentation of bidirectional mitral isthmus block . All patients were seen at 1 , 3 , 6 , and every 12 months after ablation , with 14-day continuous ECG monitoring every 6 months . At 16.4±6.3 months after 1 ablation procedure , 19 patients ( 58 % ) remained free of atrial arrhythmias after PVI versus 17 patients ( 51 % ) after CPVA+LALA ( P=0.62 ) . After PVI , 14 patients had recurrent paroxysmal AF , whereas after CPVA+LALA , 8 patients had recurrent AF , 6 had atypical left atrial flutter ( LAFL ) , and 2 had both AF and LAFL ( P=0.32 between PVI versus CPVA+LALA for AF but P=0.002 for LAFL ) . Twenty-eight patients ( 85 % ) remained arrhythmia-free after 1.3±0.5 PVI procedures versus 28 patients ( 85 % ) after 1.4±0.6 CPVA+LALA procedures ( P = NS ) . Fluoroscopy time was longer after CPVA+LALA versus PVI ( 91 versus 73 minutes , P=0.04 ) . Conclusions —As an initial ablation approach in patients with paroxysmal AF  , more LAFL occurred after CPVA+LALA and fluoroscopy times were longer compared with segmental PVI Background — Data on the comparative value of the circumferential pulmonary vein and the segmental pulmonary vein ablation for interventional treatment of atrial fibrillation are limited . We hypothesized that the circumferential pulmonary vein ablation approach was superior to the segmental pulmonary vein ablation approach . Methods and Results —One hundred patients with highly symptomatic atrial fibrillation were r and omly assigned to undergo either circumferential ( n=50 ) or segmental pulmonary vein ablation ( n=50 ) . Freedom from atrial tachyarrhythmias in a 7-day Holter monitoring at 6 months was the primary end point . Secondary end points were freedom of arrhythmia-related symptoms and a composite of pericardial tamponade , thromboembolic complications , and pulmonary vein stenosis ( safety end point ) . On the basis of the results of the 7-day Holter monitoring at 6 months , 21 patients ( 42 % ) after circumferential pulmonary vein ablation and 33 patients ( 66 % ) after segmental pulmonary vein ablation ( P=0.02 ) were free of atrial tachyarrhythmia episodes . During the 6-month follow-up period , 27 patients ( 54 % ) after circumferential pulmonary vein ablation and 41 patients ( 82 % ) after segmental pulmonary vein ablation remained free of arrhythmia-related symptoms ( P<0.01 ) . No significant difference was found in the safety end point ( 6 versus 7 events ; P=0.77 ) in the circumferential versus segmental pulmonary vein ablation group , respectively . Conclusions —This study demonstrates no superiority of the circumferential pulmonary vein ablation over segmental pulmonary vein ablation for treatment of atrial fibrillation in terms of efficacy and safety BACKGROUND The limited efficacy and complications of segmental ostial pulmonary vein isolation ( PVI ) for treating atrial fibrillation ( AF ) have been discussed so , in the present study the feasibility and efficiency of performing segmental pulmonary vein ( PV ) antrum isolation to treat AF were assessed . METHODS AND RESULTS A total of 187 patients with drug-refractory AF ( paroxysmal 120 , persistent 67 ) underwent segmental PVI guided by circumferential 20-electrode catheters ( Lasso ) . Radiofrequency ( RF ) current was delivered either at the ostium using a regular Lasso ( 15 - 20 mm in diameter , 70 patients : Group 1 ) or at the antrum using a larger Lasso ( 25 - 30 mm in diameter , 117 patients : Group 2 ) . A significantly wider region had to be ablated , with a longer RF application time , to isolate all 4 PVs in Group 2 patients than in Group 1 patients . Although the rate of recurrence of AF after the initial session was equal in both groups , a significantly greater number of patients were free from AF after a mean of 1.4 procedures in Group 2 than in Group 1 ( 93 % vs 76 % for paroxysmal AF , 78 % vs 48 % for persistent AF ) . CONCLUSIONS Segmental antral PVI using large-sized Lasso catheters was found to be more effective and safer than ostial PVI for the treatment of AF BACKGROUND Catheter ablation ( CA ) by wide encirclement of pulmonary veins ( WEPV ) restores sinus rhythm in up to 95 % . Complex PV-left atrial ( LA ) connections make achieving electrical isolation ( EI ) challenging . We examined anatomical and technical features associated with resistance to EI during WEPV in a prospect i ve study . METHODS One hundred one consecutive patients with symptomatic AF underwent first-time CA guided by electroanatomic mapping and CT integration ( Cartomerg ) . Following double-transseptal access , WEPV was performed . After completion of PV encirclement , the line was mapped and where no signal could be obtained , CA was performed inside the WE line at the site of earliest PV breakthrough on the circular mapping catheter . Sites of EI were tagged . Anatomic studies of corresponding regions of the venoatrial junction in 24 adult hearts were performed . RESULTS Sites resistant to EI were located at the inferior quadrant ( P < 0.001 ) for the RSPV , superior quadrant ( P < 0.001 ) for the RIPV , and the inferior and anterior quadrants ( P < 0.001 ) for the LSPV . EI was significantly less frequent at the posterior quadrant ( P < 0.001 ) for the LIPV . To achieve EI , CA was necessary inside the WE on the intervenous ridge on the right in 51 % and on the left in 41 % . The LPV/LAA ridge was investigated by anatomic studies that demonstrated considerable variation in the narrowest width ( 3 - 23.7 mm ) and transmural thickness ( 1 - 5 mm ) . CONCLUSION Sites of EI after WEPV have a preferential distribution determined by anatomic features . CA on the intervenous ridge is required in a significant proportion of patients to achieve EI . Atrial folds and ridges increase myocardial thickness creating technical and anatomic challenges for achieving transmural lesions BACKGROUND Electrical isolation of pulmonary veins ( PVs ) is an effective therapy for atrial fibrillation ( AF ) . Both segmental ostial PV ablation and circumferential ablation with PV-left atrial ( LA ) block have been implicated to eliminate AF . However , the mechanism of the recurrent AF after undergoing either strategy remains unclear . METHODS AND RESULTS Of the 73 consecutive patients with symptomatic AF that underwent PV isolation and had recurrences of AF , Group 1 consisted of 46 patients ( age 56 + /- 13 years old , 35 males ) who underwent PV isolation by segmental ostial PV ablation and Group 2 consisted of 27 patients ( age 51 + /- 11 years old , 24 males ) who underwent circumferential ablation with PV-LA block .  In Group 1 , the earliest ectopic beat or ostial PV potentials were targeted . In Group 2 , circumferential ablation with PV-LA block was performed by encircling the extraostial regions around the left and right PVs . During the first procedure , all patients had PV-AF . There was no difference in the non-PV ectopy between Group 1 and Group 2 . During the second procedure , the incidence of an LA posterior wall ectopy initiating AF was significantly lower ( 20 % vs. 0 % , P = 0.01 ) in Group 2 . There was no difference in the PV ectopy initiating AF during the second procedure . CONCLUSION Circumferential ablation of AF with PV-LA block may eliminate the LA posterior wall ectopy and decrease the incidence of LA posterior wall ectopy initiating AF during the second procedure Background —Ablation of the pulmonary veins ( PVs ) for atrial fibrillation treatment is often combined with linear radiofrequency lesions along the left atrium ( LA ) to improve the success rate . The study was design ed to assess the contribution of LA posterior wall isolation to the outcome of circumferential pulmonary vein ablation ( CPVA ) . Methods and Results —CPVA consisted of continuous radiofrequency lesions encircling both ipsilateral PVs plus an ablation line along the mitral isthmus . Patients were then r and omized into 2 groups . In the first group , superior PVs were connected by linear lesions along the LA roof ( CPVA-1 group ) . In the second group , the LA posterior wall was isolated by adding a second line connecting the inferior aspect of the 2 inferior PVs ( CPVA-2 group ) . The study included 120 patients ( 53±11 years , 77 % male , 60 % paroxysmal atrial fibrillation , LA of 41.3±5.4 mm , 46 % with hypertension , and 22 % with structural heart disease ) . After a single ablation procedure and a mean follow-up of 10±4 months , 24 ( 40 % ) patients of the CPVA-1 group had atrial fibrillation recurrences and 3 ( 5 % ) had new-onset LA flutter . In the CPVA-2  group , recurrences were due to atrial fibrillation episodes in 23 patients ( 38 % ) and LA flutter in 4 ( 7 % ) . Freedom from arrhythmia recurrences was not statistically different in the CPVA-1 group as compared with the CPVA-2 group ( log rank P=0.943 ) . Conclusion —Isolation of the LA posterior wall did not increase the success rate of CPVA Background : The wide area circumferential ablation ( WACA ) approach to atrial fibrillation is thought to result in ‘ substrate modification ’ perhaps related to autonomic denervation . We examined this prospect ively by comparing WACA and segmental pulmonary vein isolation ( PVI ) using noninvasive surrogate markers INTRODUCTION Circumferential pulmonary vein ablation ( CPVA ) with the endpoint of pulmonary vein ( PV ) isolation has been developed as an effective therapy for atrial fibrillation ( AF ) . This endpoint can be achieved either by closing gaps along circular lines or by segmental PV isolation inside the circular lines after creation of initial CPVA lesions . We investigated whether the clinical outcome depends on the PV isolation approach used during the first-time CPVA procedure . METHODS AND RESULTS One hundred consecutive patients ( 69 male ; age , 56.7 + /- 11.6 years ) who underwent first-time CPVA for treatment of symptomatic AF were enrolled . PV isolation was r and omly achieved either by CPVA alone ( aggressive CPVA [ A-CPVA ] group , n = 50 ) or by a combination of CPVA with segmental PV ostia ablation ( modified CPVA [ M-CPVA ] group , n = 50 ) . Recurrence of atrial tachyarrhythmias ( ATa ) within 3 months after the initial procedure occurred in 30 patients ( 60 % ) in the M-CPVA group and in only 15 patients ( 30 % ) in the A-CPVA group ( P < 0.01 ) . ATa relapse after the first 3 months was detected in 21 patients ( 42 % ) in the M-CPVA group , compared with 9 patients ( 18 % ) in the A-CPVA group ( P = 0.01 ) . At 13 + /- 4 months , patients treated by the A-CPVA approach had greater freedom from ATa recurrence than patients who underwent M-CPVA ( P = 0.01 ) . The M-CPVA approach was the only independent predictor associated with procedural failure ( RR 0.318 ; 95 % CI 0.123 - 0.821 ; P = 0.02 ) . CONCLUSIONS When PV isolation is the endpoint of CPVA , the efficacy of the A-CPVA approach is better than that of M-CPVA Background —Electric isolation of the pulmonary veins and posterior left atrium with a single ring of radiofrequency lesions ( single-ring isolation [ SRI ] ) may result in fewer atrial fibrillation ( AF ) recurrences than wide antral pulmonary vein isolation ( wide antral isolation [ WAI ] ) by abolishing extravenous AF triggers . The effect of mitral isthmus line ( MIL ) ablation on outcomes after SRI has not previously been assessed . Methods and Results —We r and omly assigned 220 consecutive patients ( 58±10 years old ; 82 % men ) with highly symptomatic AF ( 61 % paroxysmal , 39 % persistent/longst and ing persistent ) to undergo either SRI or WAI .  Half of each cohort was also r and omly allocated to have left lateral MIL ablation ( 2 × 2 factorial study design ) . Patients were followed clinical ly and with 7-day Holter studies for arrhythmia recurrences . The primary end points were recurrence of AF and organized atrial tachyarrhythmias . AF-free survival at 2 years was better after SRI ( 74 % [ 95 % CI , 65%–82 % ] ) than WAI ( 61 % [ 51%–70 % ] ; P=0.031 ) . Organized atrial tachyarrhythmia – free survival was similar after SRI and WAI ( 67 % [ 57%–75 % ] ersus 64 % [ 54%–72 % ] , respectively , at 2 years ; P=0.988 ) . MIL ablation result ed in better 2-year organized atrial tachyarrhythmia – free survival ( 71 % [ 62%–79 % ] versus 60 % [ 50%–69 % ] ; P=0.07 ) , which approached statistical significance . Survival free of any atrial arrhythmia after one procedure was not significantly affected by isolation technique or MIL ablation . Conclusions —SRI result ed in fewer AF recurrences compared with WAI on long-term follow-up but did not reduce the recurrence of all atrial arrhythmias . MIL ablation may reduce organized atrial tachyarrhythmia recurrences . Clinical Trial Registration —http://www.anzctr.org.au ; ACTRN12606000467538 AIMS Early recurrences of atrial arrhythmia after wide electrically isolating ablation for atrial fibrillation ( AF ) are well described , but the long-term risk of recurrence for patients with persistent and permanent AF has not been studied in detail . METHODS AND RESULTS Fifty-six consecutive patients [ 45 men ( 80.4 % ) , age 55.9 + /- 8.7 years ] with persistent [ 39(69.6 % ) ] or permanent [ 17(30.4 % ) ] AF were followed for 21.6 + /- 8.8 months after ablation . Atrial fibrillation duration prior to ablation was 6.4 + /- 5.6 years .  Electrically isolating lesions encircling the left and right pulmonary veins ( PVs ) in pairs were created . After 1.5 + /- 0.7 procedures , 48 ( 85.7 % ) had sinus rhythm ( SR ) at 21.6 + /- 8.8 months of follow-up : achieved with 1 procedure in 27 ( 56.3 % ) and without anti-arrhythmics in 30 ( 62.5 % ) . Atrial fibrillation recurrence was observed in 69.6 % after the first and 46.4 % after the last procedure . Of those with late recurrences ( > 90 days ) following the last procedure , most [ 18 ( 69.2 % ) ] did not have early recurrences . Pre-procedural AF duration ( P = 0.007 ) and female gender ( P = 0.005 ) were independent predictors of recurrence following the last procedure . CONCLUSION Circumferential PV isolation is effective in most patients with persistent or permanent AF . However , repeat procedures are frequently required . Late recurrences are common and not precluded by the absence of early post-procedural arrhythmias BACKGROUND Both segmental ostial and circumferential extraostial pulmonary vein ( PV ) isolation have been proven effective in the treatment of atrial fibrillation ( AF ) . However , the recurrence of AF and PV conduction after the 2 ablation strategies has never been compared in a r and omized study . METHODS A total of 100 consecutive patients ( age 56 + /- 10 ; 71 men ) with symptomatic AF ( paroxysmal , 51 ; persistent , 49 ) were r and omized to segmental ostial ( n = 54 ) or circumferential extraostial ( n = 46 ) PV isolation . A circular catheter positioned at the ostium of each target PV guided the ostial PV isolation . Extraostial PV isolation was performed by encircling the paired left and right PVs , respectively , guided by an electroanatomic mapping system . RESULTS A total of 84 % of the patients had recurrent AF after the first PV isolation procedure , showing 72 % with AF and 12 % with organized left atrial tachycardia . In patients undergoing reablation , all but 2 patients had recurrence of left atrium PV conduction ( > 95 % ) . During a mean follow-up of 12 months without antiarrhythmic medication , 57 % of patients who underwent extraostial PV isolation were free of arrhythmia symptoms compared with 31 % of patients who underwent ostial PV isolation ( P < .05 ) . This difference in success rate between the 2 ablation strategies was mainly seen in patients known with persistent AF ( 52 % and 15 % , respectively ; P = .02 ) as opposed to patients with paroxysmal AF ( 65 % and 46 % , respectively ; P = .26 ) . CONCLUSIONS Overall , the more proximal , extraostial PV isolation was found to be superior to ostial PV isolation , especially in patients known with persistent AF . A high recurrence rate of 84 % after a single complete PV isolation procedure was seen . At reablation , more than 95 % had recurrence of left atrium PV conduction regardless of the procedure used , supporting the idea that complete PV isolation seems essential to prevent arrhythmia recurrences INTRODUCTION Pulmonary vein ( PV ) isolation for atrial fibrillation ( AF ) can be performed using a segmental ostial or a circumferential extra-ostial approach . The relative merits and potential limitations of each approach are currently debated . Here we report our early experience with each of these approaches , including their relative efficacy and safety . METHODS AND RESULTS Forty patients with drug-refractory AF underwent segmental ostial PV isolation and were compared to 40 consecutive patients who underwent PV isolation using a circumferential extra-ostial approach . The latter approach described here is novel in two aspects : ( 1 ) the endpoint for ablation was PV isolation and not only delay in left atrial to PV conduction time , and ( 2 ) isolation of the right and left PVs was achieved by a single encirclement of ipsilateral veins . At follow-up , 60 % of the patients in the segmental group were free of AF compared to 75 % of the patients in the circumferential group . There was one thromboembolic cerebrovascular complication during the ablation procedure in each group . CONCLUSION PV isolation using a circumferential extra-ostial approach , where the ipsilateral PVs are isolated together by one encircling line of block using electroanatomic mapping , is a technically feasible procedure . This approach is at least as effective and safe as the more established segmental ostial approach for AF ablation
target: Our primary finding is that PVI performed with a wide antral approach is more effective than ostial PVI in achieving freedom from total atrial tachyarrhythmia recurrence at long-term follow-up
background: BACKGROUND For the past decade , electric pulmonary vein isolation ( PVI ) has become a procedure implemented worldwide for the treatment of atrial fibrillation .
  Currently , 2 main approaches are used for PVI : ostial isolation of the PVs and wide antral PVI .
  The aims of this systematic review are to evaluate the relative merits of each technique with a pooled comparative analysis of efficacy and complications .