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"Work on the back wall" in ablation
Posted by Iatrogenia
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"Work on the back wall" in ablation July 17, 2013 12:48PM |
Registered: 10 years ago Posts: 344 |
I see Shannon mentioned "work on the back wall" in a recent post -- how common is this?
I just saw Dr. Hao for my 2-week followup (ablation was done 6/27). He had said he isolated my PVs and did a little "work on the back wall."
Asked for more details, he said there were some spots on the back wall that might develop into hot spots, and ablated them. (Did not draw lines, seemed to pinpoint the ablations.)
He said my condition was as to be expected, about average. I had no fibrosis.
Is the back wall the most common site for additional hot spots? What are the usual procedures to address this?
Of course, I very much want to think I'm "one and done." How likely is this, given the "work on the back wall"?
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Lone paroxysmal vagal atrial fibrillation. Age 62, female, no risk factors. Autonomic instability since severe Paxil withdrawal in 2004, including extreme sensitivity to neuro-active drugs, supplements, foods. Monthly tachycardia started 1/11, happened only at night, during sleep, or when waking, bouts of 5-15 hours. Changed to afib about a year ago, same pattern. Frequency increased over last 6 months, apparently with sensitivity to more triggers. Ablation 6/27/13 by Steven Hao.
I just saw Dr. Hao for my 2-week followup (ablation was done 6/27). He had said he isolated my PVs and did a little "work on the back wall."
Asked for more details, he said there were some spots on the back wall that might develop into hot spots, and ablated them. (Did not draw lines, seemed to pinpoint the ablations.)
He said my condition was as to be expected, about average. I had no fibrosis.
Is the back wall the most common site for additional hot spots? What are the usual procedures to address this?
Of course, I very much want to think I'm "one and done." How likely is this, given the "work on the back wall"?
______________
Lone paroxysmal vagal atrial fibrillation. Age 62, female, no risk factors. Autonomic instability since severe Paxil withdrawal in 2004, including extreme sensitivity to neuro-active drugs, supplements, foods. Monthly tachycardia started 1/11, happened only at night, during sleep, or when waking, bouts of 5-15 hours. Changed to afib about a year ago, same pattern. Frequency increased over last 6 months, apparently with sensitivity to more triggers. Ablation 6/27/13 by Steven Hao.
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Re: "Work on the back wall" in ablation July 17, 2013 06:41PM |
Admin Registered: 11 years ago Posts: 2,779 |
Hi Iatrogenia.
Some work on the back wall of the left atrium is a very common non-PV area for ablation. Most more advanced ablationist will look to do this for most patients unless they are confident they are truly only triggers from their PVs alone. Typically, either where they find some degree if fibrosis, or a longer history of AFIB and possibly with longer episode duration and definitely when they find some added hotspots on real time mapping in the area the should and will often ablate in that area.
Its just the same thing as ablating the PVs only they typically will make a line across the back wall sometimes from the mitral isthmus and they will tend to take a specific angle and draw the line as they do based on what they find in real time mapping. There is nothing different here at all as a procedure than a standard PVAI-only ablation ... just more of it.
Other key non-PV anatomical areas in addition to the back wall of the LA are the Superior Vena Cava, Mitral isthmus and Coronary Sinus which is often isolated similar to the PVs and Left Atrial Appendage which most EPs who even go there save until last, or save for a possible second procedure to address then, if need be, unless they find significant firing from the LAA during the first ablation in which case the best EPs will take care of it as required.
No one can say, other than perhaps your EP, how likely it is that you might be one and done. The best approach in my view is to enjoy all the NSR you can get but don't be too disappointed if you wind up needing a little more work sooner or later to get things even more effectively buttoned down for a much longer period.
Sounds like you are doing well though and Dr Hao saying it was a pretty routine procedure bodes well for you too Iatrogenia, you've taken the biggest step so far toward maximizing your NSR time long term, regardless of whether you are done already or might need a bit more work down the line. Any touch up, if ever needed, will generally be simpler and even more solid.
Shannon
Shannon
The longer you have been in AFIB and the more scarring/fibrosis has built up over time from structural remodeling, the more likely it is you will reguire more work beyond PV isolation alone. But that doesnt require some new procedure, its just more of the same although it requires more skill to track down and locate real time triggers and there is more variable thickness to the atrial tissue in various parts of the LA and related areas requiring more experience to know just how much pressure and temperature to use at each area to get a good transmural burn.
Some work on the back wall of the left atrium is a very common non-PV area for ablation. Most more advanced ablationist will look to do this for most patients unless they are confident they are truly only triggers from their PVs alone. Typically, either where they find some degree if fibrosis, or a longer history of AFIB and possibly with longer episode duration and definitely when they find some added hotspots on real time mapping in the area the should and will often ablate in that area.
Its just the same thing as ablating the PVs only they typically will make a line across the back wall sometimes from the mitral isthmus and they will tend to take a specific angle and draw the line as they do based on what they find in real time mapping. There is nothing different here at all as a procedure than a standard PVAI-only ablation ... just more of it.
Other key non-PV anatomical areas in addition to the back wall of the LA are the Superior Vena Cava, Mitral isthmus and Coronary Sinus which is often isolated similar to the PVs and Left Atrial Appendage which most EPs who even go there save until last, or save for a possible second procedure to address then, if need be, unless they find significant firing from the LAA during the first ablation in which case the best EPs will take care of it as required.
No one can say, other than perhaps your EP, how likely it is that you might be one and done. The best approach in my view is to enjoy all the NSR you can get but don't be too disappointed if you wind up needing a little more work sooner or later to get things even more effectively buttoned down for a much longer period.
Sounds like you are doing well though and Dr Hao saying it was a pretty routine procedure bodes well for you too Iatrogenia, you've taken the biggest step so far toward maximizing your NSR time long term, regardless of whether you are done already or might need a bit more work down the line. Any touch up, if ever needed, will generally be simpler and even more solid.
Shannon
Shannon
The longer you have been in AFIB and the more scarring/fibrosis has built up over time from structural remodeling, the more likely it is you will reguire more work beyond PV isolation alone. But that doesnt require some new procedure, its just more of the same although it requires more skill to track down and locate real time triggers and there is more variable thickness to the atrial tissue in various parts of the LA and related areas requiring more experience to know just how much pressure and temperature to use at each area to get a good transmural burn.
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Re: "Work on the back wall" in ablation July 17, 2013 06:52PM |
Registered: 10 years ago Posts: 344 |
Thanks, Shannon. I tried to get it out of him, but Dr. Hao won't estimate how likely it is I'm "one and done."
I asked him about lines across the back wall, but he more or less said that's a theoretical construct, he didn't draw lines.
Do hot spots tend to spread from the PVs to back wall and elsewhere in some kind of pattern or are they more randomly distributed?
______________
Lone paroxysmal vagal atrial fibrillation. Age 62, female, no risk factors. Autonomic instability since severe Paxil withdrawal in 2004, including extreme sensitivity to neuro-active drugs, supplements, foods. Monthly tachycardia started 1/11, happened only at night, during sleep, or when waking, bouts of 5-15 hours. Changed to afib about a year ago, same pattern. Frequency increased over last 6 months, apparently with sensitivity to more triggers. Ablation 6/27/13 by Steven Hao.
I asked him about lines across the back wall, but he more or less said that's a theoretical construct, he didn't draw lines.
Do hot spots tend to spread from the PVs to back wall and elsewhere in some kind of pattern or are they more randomly distributed?
______________
Lone paroxysmal vagal atrial fibrillation. Age 62, female, no risk factors. Autonomic instability since severe Paxil withdrawal in 2004, including extreme sensitivity to neuro-active drugs, supplements, foods. Monthly tachycardia started 1/11, happened only at night, during sleep, or when waking, bouts of 5-15 hours. Changed to afib about a year ago, same pattern. Frequency increased over last 6 months, apparently with sensitivity to more triggers. Ablation 6/27/13 by Steven Hao.
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Re: "Work on the back wall" in ablation July 17, 2013 07:57PM |
Admin Registered: 11 years ago Posts: 2,779 |
I can understand Dr Hao's reluctance to guess if you are finished now. It would just be a guess in any event and the best he could say was that you've had the major part if your work done and it may well be enough to keep you quiet for the long haul, but there is roughly a 20% to 30% chance you could need a touch up to anywhere from the next 6 months on out with the likelihood of needing more work increasing around year four to five and beyond.That's the most prudent thing to say.
You may be done for 15years or you may need a touch up in 3 months, so just enjoy the ride in tge knowledge that you've got the bulk of any ablation work behind you already, the rest is pretty much downhill from here regardless if you might need another visit to Hao's EP Lab at some point to fine tune things a bit.
AFIB triggers tend to spread outward from places of fibrosis as it progresses, which largely represents electrically stunted areas of atrial myocardium, to any of the common culprit areas described above, including any focal trigger points snywhere in the LA where CAFEs (Complex Fractionated Electrograms) that can still support a sustained arrhythmia are still active.
You are still very much a 'newbie' as far as AFIB experience and burden goes so count that as a big plus in your column and relax with that and that you've taken a major step already to keep on top of this thing.
Shannon
You may be done for 15years or you may need a touch up in 3 months, so just enjoy the ride in tge knowledge that you've got the bulk of any ablation work behind you already, the rest is pretty much downhill from here regardless if you might need another visit to Hao's EP Lab at some point to fine tune things a bit.
AFIB triggers tend to spread outward from places of fibrosis as it progresses, which largely represents electrically stunted areas of atrial myocardium, to any of the common culprit areas described above, including any focal trigger points snywhere in the LA where CAFEs (Complex Fractionated Electrograms) that can still support a sustained arrhythmia are still active.
You are still very much a 'newbie' as far as AFIB experience and burden goes so count that as a big plus in your column and relax with that and that you've taken a major step already to keep on top of this thing.
Shannon
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Re: "Work on the back wall" in ablation July 18, 2013 11:52AM |
Registered: 10 years ago Posts: 344 |
Thanks, Shannon.
______________
Lone paroxysmal vagal atrial fibrillation. Age 62, female, no risk factors. Autonomic instability since severe Paxil withdrawal in 2004, including extreme sensitivity to neuro-active drugs, supplements, foods. Monthly tachycardia started 1/11, happened only at night, during sleep, or when waking, bouts of 5-15 hours. Changed to afib about a year ago, same pattern. Frequency increased over last 6 months, apparently with sensitivity to more triggers. Ablation 6/27/13 by Steven Hao.
______________
Lone paroxysmal vagal atrial fibrillation. Age 62, female, no risk factors. Autonomic instability since severe Paxil withdrawal in 2004, including extreme sensitivity to neuro-active drugs, supplements, foods. Monthly tachycardia started 1/11, happened only at night, during sleep, or when waking, bouts of 5-15 hours. Changed to afib about a year ago, same pattern. Frequency increased over last 6 months, apparently with sensitivity to more triggers. Ablation 6/27/13 by Steven Hao.
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Re: "Work on the back wall" in ablation July 21, 2013 02:13PM |
Registered: 10 years ago Posts: 344 |
Shannon, is this "work on the back wall" typically ablation of fractionated signals or complex fractionated atrial electrograms (CFAE -- see Pubmed article)?
From 2006 Medscape article (requires free registration):
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Lone paroxysmal vagal atrial fibrillation. Age 62, female, no risk factors. Autonomic instability since severe Paxil withdrawal in 2004, including extreme sensitivity to neuro-active drugs, supplements, foods. Monthly tachycardia started 1/11, happened only at night, during sleep, or when waking, bouts of 5-15 hours. Changed to afib about a year ago, same pattern. Frequency increased over last 6 months, apparently with sensitivity to more triggers. Ablation 6/27/13 by Steven Hao.
From 2006 Medscape article (requires free registration):
Quote
....complex fractionated atrial electrograms (CFAEs) were observed mostly in areas of slow conduction and/or at pivot points where the wavelets turn around at the end of the arcs of functional blocks.[6] These areas of CFAEs during AF represent either continuous reentry of the fibrillation waves into the same area or overlap of different wavelets entering the same area at different times. This complex electrical activity was characterized in these studies by a relatively short cycle length and heterogeneous temporal and spatial distribution in humans.
These observation led Nademanee and colleagues[7] to hypothesize that if the areas of CFAEs could be identified with catheter mapping during AF, it would then be possible to locate the areas where the AF wavelets reenter. They hypothesized that if such areas were then selectively eliminated by catheter ablation, wavelet reentry would stop, thereby preventing perpetuation of AF. Accordingly, they studied the effect of targeting these sites of CFAE activity to convert patients with AF to sinus rhythm.....
In their study, a total of 121 patients with drug-refractory AF (57 paroxysmal, 64 chronic) underwent catheter mapping and ablation of the CFAE areas. CFAE sites were mainly confined to the interatrial septum, PVs, roof of left atrium, left posteroseptal mitral annulus, and coronary sinus ostium. Ablation of the areas associated with CFAEs resulted in termination of AF without external cardioversion in 115 of the 121 patients (95%); 32 (28%) required concomitant ibutilide treatment. At 1-year follow-up, 110 (91%) patients were free of arrhythmia and symptoms without the need for repeat ablation; 92 patients achieved this outcome after 1 additional ablation and 18 patients after 2 ablations. The study authors concluded from this experience that CFAEs represent the electrophysiologic substrate for AF and can be effectively targeted for ablation to achieve normal sinus rhythm.
Despite the clinical efficacy seen in this study, one of the difficulties that other investigators have encountered in trying to reproduce these results is the relative subjectivity inherent in defining whether a particular electrogram is "complex" enough....
Given the current clinical data, the most common approach to catheter ablation of paroxysmal AF is electrical PV isolation. However, the approach that is employed for catheter ablation of chronic AF has evolved to an approach that incorporates strategies to address both the AF triggers and AF perpetuators, that is, electrical isolation of the PVs to isolate the former, and ablation within the atria to eliminate the latter. Specifically, this stepwise approach initially involves electrical PV isolation — and in selected patients, ablation of other focal sites located in the superior vena cava, etc. Then, CFAE sites are targeted in the left atrium, particularly the interatrial septum, the base of the left atrial appendage, and the inferior left atrium along the coronary sinus. In addition, CFAE sites are frequently identified and targeted within the body of the coronary sinus. In selected patients, CFAE sites are also located within the right atrium; typically, these sites are targeted last. In the course of this progressive ablation strategy, the rhythm often converts from AF to an organized macro- or microreentrant atrial tachycardia (ATs). Then, these organized ATs are targeted for ablation to terminate the rhythm to sinus.....
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Lone paroxysmal vagal atrial fibrillation. Age 62, female, no risk factors. Autonomic instability since severe Paxil withdrawal in 2004, including extreme sensitivity to neuro-active drugs, supplements, foods. Monthly tachycardia started 1/11, happened only at night, during sleep, or when waking, bouts of 5-15 hours. Changed to afib about a year ago, same pattern. Frequency increased over last 6 months, apparently with sensitivity to more triggers. Ablation 6/27/13 by Steven Hao.
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Re: "Work on the back wall" in ablation July 21, 2013 02:58PM |
Registered: 10 years ago Posts: 344 |
And here (PDF download) is a 2009 paper Atrial Fibrillation Ablation Strategies for Paroxysmal Patients to which my EP, Steven Hao, contributed (as well as everybody who is anybody among EPs), which found PVI followed by CFAE ablation was insignificantly more effective than PVI alone.
It contains some stats regarding lesions for CFAEs on the posterior wall.
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Lone paroxysmal vagal atrial fibrillation. Age 62, female, no risk factors. Autonomic instability since severe Paxil withdrawal in 2004, including extreme sensitivity to neuro-active drugs, supplements, foods. Monthly tachycardia started 1/11, happened only at night, during sleep, or when waking, bouts of 5-15 hours. Changed to afib about a year ago, same pattern. Frequency increased over last 6 months, apparently with sensitivity to more triggers. Ablation 6/27/13 by Steven Hao.
It contains some stats regarding lesions for CFAEs on the posterior wall.
Quote
Hybrid Approach: PVAI Followed by Ablation of CFAEs (Group III) This ablation strategy was a combination of the 2 previously described approaches. PVAI was followed by CFAEs ablation; therefore patients underwent antrum isolation of all pulmonary veins and subsequently the elimination of CFAEs in both atria.
The procedural end point for this strategy was the complete elimination of CFAEs areas and electric isolation of all the PV antra defined by entrance and exit block....
The pulmonary veins are known for their preponderant role in triggering and maintaining AF.2 Segmental ostial pulmonary vein isolation maintains sinus rhythm in approximatively 2/3 of the patients with paroxysmal AF.12,13 Additional lesions such as mitral isthmus ablation5 or antrum isolation14 have been reported to increase this success to approximately 90%. More recently, ablation targeting CFAEs has been shown to result in sinus rhythm maintenance in approximately 80% of patients with paroxysmal and persistent AF.3....
Based on our findings, additional sites of ablation [to PVAI] should be reserved for selected patients, and probably should not be driven by empirical targeting of fragmented electrograms but by mapping triggers disclosed with administration of isopro- terenol or adenosine. Several other groups have shown that ablation strategies encompassing the areas equivalent to the antrum achieve similar results and are better than more limited approaches....
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Lone paroxysmal vagal atrial fibrillation. Age 62, female, no risk factors. Autonomic instability since severe Paxil withdrawal in 2004, including extreme sensitivity to neuro-active drugs, supplements, foods. Monthly tachycardia started 1/11, happened only at night, during sleep, or when waking, bouts of 5-15 hours. Changed to afib about a year ago, same pattern. Frequency increased over last 6 months, apparently with sensitivity to more triggers. Ablation 6/27/13 by Steven Hao.
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