Despite the success of ablation treatment for patients with atrial fibrillation (AF), a standardized approach using the same lesion set for every patient might not be the best option. A more tailored approach that targets the specific triggers and drivers of AF in each patient could be more successful.OBJECTIVE
To find out whether patients with paroxysmal AF can be treated successfully by catheter ablation specific to their individual electrophysiological AF characteristics.DESIGN
Oral et al. included consecutive patients who had symptomatic paroxysmal AF and had not undergone previous ablation procedures. All patients had scheduled left atrial ablation procedures to treat their AF.INTERVENTION
Eligible patients underwent ablation with a temperature-controlled 8 mm tip radiofrequency catheter. Barium sulfate esophageal cream was given to each patient for visualization of their esophagus, and ablation proximal to the esophagus was avoided if possible. If patients were in sinus rhythm, rapid atrial pacing was used to induce AF so that the pulmonary veins and left atrium could be mapped. The resulting pulmonary vein tachycardias were then treated by pulmonary vein isolation or encirclement, or ablation of an arrhythmogenic fascicle. If AF was still recurring, whether spontaneously or after induction, patients underwent left atrial mapping to identify electrograms in the left atrium, coronary sinus or superior vena cava. These sites were then targeted for ablation. Patients were discharged after one night's hospital stay and were followed up at 3 months and every 3 months thereafter. All patients received heparin and warfarin, and those who had received antiarrhythmic therapy before intervention or had recurrent AF or atrial flutter were given further antiarrhythmic medication.OUTCOME MEASURES
SThe main endpoint was the elimination of AF or the inability to induce AF.RESULTS
In total 153 patients underwent ablation and completed follow-up. Of these, AF was rendered noninducible following intervention in 88 (57.5%) patients. After ablation, 29 (19%) patients developed left atrial flutter, which was still present in 15 (10%) patients after 12 weeks' follow-up. Notably, 28 (18%) patients had to undergo repeat ablation because of recurrent AF or atypical atrial flutter, after an average follow-up of 8 ± 2 months. After 11 ± 4 months, 118 (77%) patients had no more episodes of AF or atrial flutter; furthermore, these patients were not receiving antiarrhythmic medication. The long-term efficacy of tailored ablation (i.e. absence of recurrent AF or atrial flutter) was significantly raised in the patients in whom AF was no longer inducible following ablation compared with the patients in whom noninducibility was not achieved (88% versus 66% of patients had no recurrent AF or atrial flutter; P = 0.003).CONCLUSIONS
The authors concluded that targeting individual driver tachycardias and complex electrograms - a tailored ablation procedure - prevents recurrent AF or atrial flutter successfully in patients with paroxysmal AF.