Two-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 fibrillation (CAF) plus a few encouraging clinical reports have created a paradigm shift regarding treatment strategies and the potential for restoring normal sinus rhythm (NSR) utilizing available catheter-based ablation techniques. The initial and late follow-up clinical experience with a two-staged biatrial linear and focal radiofrequency ablation (BALF I, II) procedure to restore NSR in patients with CAF are described. Pre-BALF management included confirming drug refractoriness and optimizing anticoagulation therapy. BALF I and II were preceded by transesophageal echocardiography to exclude thrombus. Femoral venous catheters were placed in the left atrium and the right atrium with extensive left atrial mapping ablation (linear and focal) and more limited right atrial ablation. Localized electrogram recordings demonstrated rapid, localized, stable focal driving rotors (FDRs) in the left atrium (nine patients) and in the right atrium (one patient). Atrial or intraatrial tachycardia (IAT) commonly recurred after BALF I. BALF II addresses these recurrences by repeat mapping and ablation techniques. There were no thromboembolic complications. Two patients developed pericardial tamponade that responded to medical management. Of the 11 patients with late follow-up data, 9 have NSR, atrial function, and are no longer experiencing CAF. Left atrial ablation lines decrease continuous electrogram activity, probably isolate portions of the atrium, and unmask FDRs. Focal and linear ablations appear helpful in transforming CAF to NSR. FDRs are commonly localized to pulmonary vein ostium, trabeculated portions of the atrium, and left atrial appendage.