Atrial Fibrillation: Anatomical Guidance Is Superior to Electrophysiological Guidance for Ablation

  • C. Pappone
  • V. Santinelli
Conference paper


Electrophysiologically guided ablation was the initial strategy applied in patients with focal atrial fibrillation (AF), but electroanatomical mapping systems have had an increasingly important role in successful elimination of both paroxysmal and chronic AF [1–3]. Currently, targets for ablation of AF are increasingly being selected on the basis of anatomical considerations [4–14]. Therefore, ablation strategies that are based more on anatomical considerations than on mapping are needed to improve the efficacy of catheter ablation of AF. It has become accepted that detailed anatomical knowledge of the number, size, and shape of the pulmonary veins (PVs), especially the atriopulmonary junction and the tributaries and branching pattern of the PVs, is of critical importance in PV ablation for AF. Recent experimental studies have demonstrated a correlation between anatomy and electrical activation; in particular, segmental muscle disconnection, a differential muscle narrowing at PV-LA junctions, and complex fiber orientations within the PV provide robust anatomical bases for conduction disturbances at the PV-LA junction and complex intra-PV conduction patterns. Consequently, new technologies, including the CARTO system using detailed anatomical images, have become available for catheter guidance and mapping, and their practicability has been validated by our group [2, 3]. Therefore, the importance of anatomically based catheter ablation procedures is now well recognized. Catheter ablation of isthmusdependent atrial flutter, which is based strictly on anatomical criteria, is regarded as the first-line therapy in atrial flutter. Similarly, the results of catheter ablation for AF have become better and better as procedures have been based increasingly on anatomical considerations. Therefore, future mapping technology that provides more specific anatomical information on critical areas will ultimately result in catheter ablation becoming first-line therapy for both paroxysmal and chronic AF.


Atrial Fibrillation Pulmonary Vein Catheter Ablation Atrial Flutter Pulmonary Vein Stenosis 
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  1. 1.
    Haissaguerre M, Jais P, Shah DC et al (1998) Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med 339:659–666PubMedCrossRefGoogle Scholar
  2. 2.
    Pappone C, Rosanio S, Oreto G et al (2000) Circumferential radiofrequency ablation of pulmonary vein ostia: a new anatomic approach for curing atrial fibrillation. Circulation 102:2619–2628PubMedCrossRefGoogle Scholar
  3. 3.
    Pappone C, Oreto G, Rosanio S et al (2001) Atrial electroanatomic remodeling after circumferential radiofrequency pulmonary vein ablation: efficacy of an anatomic approach in a large cohort of patients with atrial fibrillation. Circulation 104:2539–2544PubMedCrossRefGoogle Scholar
  4. 4.
    Kato R, Lickfett L, Meininger G et al (2003) Pulmonary vein anatomy in patients undergoing catheter ablation of atrial fibrillation: lessons learned by use of magnetic resonance imaging. Circulation 107:2004–2010PubMedCrossRefGoogle Scholar
  5. 5.
    Ho SY (2003) Pulmonary vein ablation in atrial fibrillation: does anatomy matter? J Cardiovasc Electrophysiol 14:156–157PubMedCrossRefGoogle Scholar
  6. 6.
    Honjo H, Boyett MR, Niwa R et al (2003) Pacing-induced spontaneous activity in myocardial sleeves of pulmonary veins after treatment with ryanodine. Circulation 107:1937–1943PubMedCrossRefGoogle Scholar
  7. 7.
    Weerasooriya R, Macle L, Jais P, Hocini M, Haissaguerre M (2003) Pulmonary vein ablation using the LocaLisa nonfluoroscopic mapping system. J Cardiovasc Electrophysiol 14:112PubMedCrossRefGoogle Scholar
  8. 8.
    Wittkampf FH, Vonken EJ, Derksen R et al (2003) Pulmonary vein ostium geometry: analysis by magnetic resonance angiography. Circulation 107:21–23PubMedCrossRefGoogle Scholar
  9. 9.
    Solomon SB, Dickfeld T, Calkins H (2003) Real-time cardiac catheter navigation on three-dimensional CT images. J Interv Card Electrophysiol 8:27–36PubMedCrossRefGoogle Scholar
  10. 10.
    Mangrum JM, Mounsey JP, Kok LC, DiMarco JP, Haines DE (2002) Intracardiac echo-cardiography-guided, anatomically based radiofrequency ablation of focal atrial fibrillation originating from pulmonary veins. J Am Coll Cardiol 39:1964–1972PubMedCrossRefGoogle Scholar
  11. 11.
    Ho SY, Cabrera JA, Tran VH et al (2001) Architecture of the pulmonary veins: relevance to radiofrequency ablation. Heart 86:265–270PubMedCrossRefGoogle Scholar
  12. 12.
    Moubarak JB, Rozwadowski JV, Strzalka CT et al (2000) Pulmonary veins-left atrial junction: anatomic and histological study. Pacing Clin Electrophysiol 23:1836–1838PubMedGoogle Scholar
  13. 13.
    Hocini M, Ho SY, Kawara T et al (2002) Electrical conduction in canine pulmonary veins: electrophysiological and anatomic correlation. Circulation 105:2442–2448PubMedCrossRefGoogle Scholar
  14. 14.
    Scharf C, Sneider M, Case I et al (2003) Anatomy of the pulmonary veins in patients with atrial fibrillation and effects of segmental ostial ablation analyzed by computed tomography. J Cardiovasc Electrophysiol 14:150–155PubMedCrossRefGoogle Scholar
  15. 15.
    Arentz T, Jander N, von Rosenthal J et al (2003) Incidence of pulmonary vein stenosis 2 years after radiofrequency catheter ablation of refractory atrial fibrillation. Eur Heart J 24:963–969PubMedCrossRefGoogle Scholar
  16. 16.
    Saad EB, Marrouche NF, Saad CP et al (2003) Pulmonary vein stenosis after catheter ablation of atrial fibrillation: emergence of a new clinical syndrome. Ann Intern Med 15:138:634–638Google Scholar
  17. 17.
    Haissaguerre M, Jais P, Shah DC et al (2000) Catheter ablation of chronic atrial fibrillation targeting the reinitiating triggers. J Cardiovasc Electrophysiol 11:2–10PubMedCrossRefGoogle Scholar
  18. 18.
    Haissaguerre M, Shah DC, Jais P et al (2000) Electrophysiological breakthroughs from the left atrium to the pulmonary veins. Circulation 102:2463–2465PubMedCrossRefGoogle Scholar
  19. 19.
    Oral H, Knight BP, Ozaydin M et al (2002) Segmental ostial ablation to isolate the pulmonary veins during atrial fibrillation: feasibility and mechanistic insights. Circulation 106:1256–1262PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Italia 2004

Authors and Affiliations

  • C. Pappone
    • 1
  • V. Santinelli
    • 1
  1. 1.Department of Cardiology, Cardiac ElectrophysiologySan Raffaele University HospitalMilanItaly

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