The modified ablation index: a novel determinant of acute pulmonary vein reconnections after pulmonary vein isolation
- 327 Downloads
Although pulmonary vein isolation (PVI) guided by the ablation index (AI) has been well-developed, acute PV reconnections (PVRs) still occur. This study aimed to compare the prognostic performance of the modified AI and its optimal cut-off value for the prediction of acute PVRs to ensure durable PVI.
Three-dimensional left atrium (LA) voltage maps created before an extensive encircling PVI in 64 patients with atrial fibrillation (AF) (45 men, 62 ± 10 years) were examined for an association between electrogram voltage amplitude recorded from the PV–LA junction and acute post-PVI PVRs (spontaneous PVRs and/or ATP-provoked dormant PV conduction).
Acute PVRs were observed in 22 patients (34%) and 33 (3%) of the 1012 PV segments. Acute PVRs were significantly associated with segments with higher bipolar voltage zones (3.23 ± 1.17 vs. 1.97 ± 1.20 mV, P < 0.0001), lower mean AI values (449 [428–450] vs. 460 [437–486], P = 0.05), and radiofrequency lesion gaps ≥ 6 mm (48 vs. 32%, P = 0.04), but not with contact force, force–time integral, or power. We created the modified AI calculated as AI/LA bipolar voltage, and found it to be significantly lower in areas with acute PVRs than in those without (152 [109–185] vs. 256 [176–413] AU/mV, P < 0.0001). Univariate analysis showed the prognostic performance of the modified AI, with an area under the curve of 0.801 (0.775–0.825), to be the highest of all the significant parameters.
Low values of the novel modified AI on the PV-encircling ablation line were strongly associated with acute PVRs.
KeywordsAtrial fibrillation Pulmonary vein isolation Catheter ablation Ablation index High-voltage zone Force–time integral
Area under the curve
Extensive encircling pulmonary vein isolation
Left inferior pulmonary vein
Left superior pulmonary vein
Pulmonary vein isolation
Pulmonary vein reconnection
Right inferior pulmonary vein
Right superior pulmonary vein
The study was supported by departmental resources only.
Compliance with ethical standards
Conflict of interest
The authors have no conflict of interest to declare.
- 1.Neuzil P, Reddy VY, Kautzner J, Petru J, Wichterle D, Shah D, et al. Electrical reconnection after pulmonary vein isolation is contingent on contact force during initial treatment: results from the EFFICAS I study. Circ Arrhythm Electrophysiol. 2013;6(2):327–33. https://doi.org/10.1161/circep.113.000374.CrossRefPubMedGoogle Scholar
- 2.Reddy VY, Shah D, Kautzner J, Schmidt B, Saoudi N, Herrera C, et al. The relationship between contact force and clinical outcome during radiofrequency catheter ablation of atrial fibrillation in the TOCCATA study. Heart Rhythm. 2012;9(11):1789–95. https://doi.org/10.1016/j.hrthm.2012.07.016.CrossRefPubMedGoogle Scholar
- 3.Phlips T, Taghji P, El Haddad M, Wolf M, Knecht S, Vandekerckhove Y, et al. Improving procedural and one-year outcome after contact force-guided pulmonary vein isolation: the role of interlesion distance, ablation index, and contact force variability in the ‘CLOSE’-protocol. EUROPACE. 2018. https://doi.org/10.1093/europace/eux376.
- 4.Das M, Loveday JJ, Wynn GJ, Gomes S, Saeed Y, Bonnett LJ, et al. Ablation index, a novel marker of ablation lesion quality: prediction of pulmonary vein reconnection at repeat electrophysiology study and regional differences in target values. EUROPACE. 2017;19(5):775–83. https://doi.org/10.1093/europace/euw105.CrossRefPubMedGoogle Scholar
- 6.Taghji P, El Haddad M, Phlips T, Wolf M, Knecht S, Vandekerckhove Y, et al. Evaluation of a strategy aiming to enclose the pulmonary veins with contiguous and optimized radiofrequency lesions in paroxysmal atrial fibrillation: a pilot study. JACC Clin Electrophysiol. 2018;4(1):99–108. https://doi.org/10.1016/j.jacep.2017.06.023.CrossRefPubMedGoogle Scholar
- 7.Baldinger SH, Kumar S, Barbhaiya CR, Nagashima K, Epstein LM, John R, et al. The timing and frequency of pulmonary veins unexcitability relative to completion of a wide area circumferential ablation line for pulmonary vein isolation. JACC Clin Electrophysiol. 2016;2(1):14–23. https://doi.org/10.1016/j.jacep.2015.09.010.CrossRefPubMedGoogle Scholar
- 9.Arujuna A, Karim R, Caulfield D, Knowles B, Rhode K, Schaeffter T, et al. Acute pulmonary vein isolation is achieved by a combination of reversible and irreversible atrial injury after catheter ablation: evidence from magnetic resonance imaging. Circ Arrhythm Electrophysiol. 2012;5(4):691–700. https://doi.org/10.1161/circep.111.966523.CrossRefPubMedGoogle Scholar
- 10.Nagashima K, Watanabe I, Okumura Y, Iso K, Takahashi K, Watanabe R, et al. High-voltage zones within the pulmonary vein antra: major determinants of acute pulmonary vein reconnections after atrial fibrillation ablation. J Interv Card Electrophysiol. 2017;49(2):137–45. https://doi.org/10.1007/s10840-017-0252-8.CrossRefPubMedGoogle Scholar
- 11.Okumura Y, Watanabe I, Iso K, Nagashima K, Sonoda K, Sasaki N, et al. Clinical utility of automated ablation lesion tagging based on catheter stability information (VisiTag module of the CARTO 3 system) with contact force-time integral during pulmonary vein isolation for atrial fibrillation. J Interv Card Electrophysiol. 2016;47:245–52. https://doi.org/10.1007/s10840-016-0156-z.CrossRefPubMedGoogle Scholar
- 12.Kautzner J, Neuzil P, Lambert H, Peichl P, Petru J, Cihak R, et al. EFFICAS II: optimization of catheter contact force improves outcome of pulmonary vein isolation for paroxysmal atrial fibrillation. EUROPACE. 2015;17(8):1229–35. https://doi.org/10.1093/europace/euv057.CrossRefPubMedPubMedCentralGoogle Scholar
- 13.Macle L, Khairy P, Weerasooriya R, Novak P, Verma A, Willems S, et al. Adenosine-guided pulmonary vein isolation for the treatment of paroxysmal atrial fibrillation: an international, multicentre, randomised superiority trial. Lancet (London, England). 2015;386(9994):672–9. https://doi.org/10.1016/s0140-6736(15)60026-5.CrossRefGoogle Scholar
- 14.Matsuo S, Yamane T, Date T, Inada K, Kanzaki Y, Tokuda M, et al. Reduction of AF recurrence after pulmonary vein isolation by eliminating ATP-induced transient venous re-conduction. J Cardiovasc Electrophysiol. 2007;18(7):704–8. https://doi.org/10.1111/j.1540-8167.2007.00842.x.CrossRefPubMedGoogle Scholar
- 16.Iso K, Okumura Y, Watanabe I, Nagashima K, Sonoda K, Kogawa R, et al. Wall thickness of the pulmonary vein-left atrial junction rather than electrical information as the major determinant of dormant conduction after contact force-guided pulmonary vein isolation. J Interv Card Electrophysiol. 2016;46:325–33. https://doi.org/10.1007/s10840-016-0147-0.CrossRefPubMedGoogle Scholar