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non-PV triggers

Atrial Fibrillation PVI: Can the Need for Multiple Ablations be Forecasted?

Could the necessity for multiple ablation procedures be predicted? According to a research study, the answer is YES!

In a study of patients who had catheter ablation of the Pulmonary Veins (PVs) for paroxysmal (occasional) A-Fib, 8% had to have more than two ablations to be A-Fib free.

The only independent predictor of the need for multiple procedures was the presence of non-PV triggers. According to this research, electrophysiologists (EPs) should check for non-PV triggers such as at the ligament of Marshall.

Illustration of RF ablation at A-Fib.com

Illustration of RF ablation

The lesson to be learned from this study: When having an ablation, make sure your Electrophysiologist (EP) is experienced at tracking down (mapping) and ablating (isolating) non-PV triggers.

For example, I reviewed the an O.R. (Operating Room) report of a patient who, after isolating the PVs, was still in A-Fib. Instead of looking for non-PV triggers, the EP just electrocardioverted the patient back into sinus rhythm. This does sometimes work. But not in this case. The ablation failed.

This is particularly important for EPs doing CryoBalloon ablations.

Graphic: Cryoablation heat withdrawl at A-Fib.com

Illustration: Cryoablation heat withdrawl

Find EPs Experienced at Ablating Non-PV Triggers

When getting a CryoBalloon ablation, you need to find an EP who is willing to do more than just isolate your PVs—someone who will put out the extra effort to find and ablate non-PV triggers such as at the ligament of Marshall.

To do this, your EP may have to replace the CryoBalloon catheter with an RF catheter to ablate these non-PV triggers. This may require mapping and ablation skills not all EPs have.

What to Ask Prospective EPs

To find the right EP for your CryoBalloon ablation ask:

What do you do if I’m still in A-Fib after you do the CryoBalloon ablation?

(You want to hear they’ll search for and ablate non-PV triggers.)

For more about Ablating Non-PV Triggers, see my article: CryoBalloon Ablation Study: 30% of Patients Required RF to Achieve Isolation

Note: This research study was conducted before the widespread use of Contact Force sensing catheters, whose use is another contributor to the reduction of recurrence and need for multiple ablation procedures.

References for this article

A-Fib Non-PV Triggers Predict Need for Multiple Ablations

Could the necessity for multiple ablation procedures be predicted? According to a new research study, the answer is YES!

In a study of patients who had catheter ablation of the Pulmonary Veins (PVs) for paroxysmal (occasional) A-Fib, 8% had to have more than two ablations to be A-Fib free.

The only independent predictor of the need for multiple procedures was the presence of non-PV triggers. According to this research, EPs should check for non-PV triggers such as at the ligament of Marshall.

This 2015 published study was done before the widespread use of Contact Force sensing catheters which seem to have reduced recurrence and the need for multiple ablation procedures.

What This Means to Patients

The lesson to be learned from this study: When having an ablation, make sure your Electrophysiologist (EP) is experienced at tracking down (mapping) and ablating (isolating) non-PV triggers.

For example, I recently read an O.R. (Operating Room) report of a patient who, after isolating the PVs, was still in A-Fib. Instead of looking for non-PV triggers, the EP just electrocardioverted the patient back into sinus rhythm. This does sometimes work. But not in this case. The ablation failed.

This is particularly important for EPs doing CryoBalloon ablations.

Arctic Cryoballoon Catheter

Arctic Cryoballoon Catheter

Find EPs Experienced at Ablating Non-PV Triggers

When getting a CryoBalloon ablation, you need to find an EP who is willing to do more than just isolate your PVs—someone who will put out the extra effort to find and ablate non-PV triggers such as at the ligament of Marshall.

To do this, your EP may have to replace the CryoBalloon catheter with an RF catheter to ablate these non-PV triggers. This may require mapping and ablation skills not all EPs have.

What to Ask Prospective EPs

To find the right EP for your CryoBalloon ablation ask:

What do you do if I’m still in A-Fib after you do the CryoBalloon ablation?

(You want to hear they’ll search for and ablate non-PV triggers.)

For more about Ablating Non-PV Triggers, see my article: CryoBalloon Ablation Study: 30% of Patients Required RF to Achieve Isolation

See the glossary for Ligament of Marshall.

References for this article

A-Fib Producing Spots Outside the Pulmonary Veins – 2014 Boston AF Symposium

Vivek Reddy Mt Sinai Hospital

Dr Vivek Reddy Mt Sinai Hospital

2014 Boston AF Symposium

A-Fib Producing Spots Outside the Pulmonary Veins

Report by Dr. Steve S. Ryan, PhD

Dr. Vivek Reddy of Mount Sinai Hospital in New York gave a presentation entitled “What is the true rate of Non-PV triggers?”

Why do ablations fail?

Dr. Reddy posed the question, ‘Why do ablations fail?’ The most common reason is a gap in an ablation lesion. Dr. Reddy showed slides of a typical wide area antrum isolation ablation with remarkably precise point-by-point burns. But there was a slight gap which let A-Fib signals escape from the pulmonary veins into the rest of the heart. But Non-PV triggers can also cause ablation failure.

Dr. Reddy asked the BAFS attendees:

“What is the rate of non-PV triggers after an extra-ostial PV isolation procedure?”

The choices ranged from 5% to over 25%.

The actual rate of non-PV triggers is approximately 23%.

Carina important origin of A-Fib triggers

Dr. Reddy showed how the ‘carina’ (the area in the heart between the left and right pulmonary vein openings) is often a source of A-Fib triggers and of recurrence after an ablation. According to the study cited, “the carina region (has an) apparently unique electrical behavior.” To effectively isolate PVs, it is frequently necessary to target within the circumferentially ablated veins in the carina region, even though there is a risk of stenosis.

Where are the non-PV triggers usually from?

In an older study of 248 Paroxysmal A-Fib patients, 28% had non-PV triggers. (These earlier studies often used segmental or ostial isolation and weren’t as durable as later procedures.) The most common locations were:

▪  LA Posterior Free Wall: 38% ▪  Superior Vena Cava: 37% ▪  Crista Terminalis: 13.7% ▪  Ligament of Marshall: 8.2%

(In this study, the Carina area and newer areas of interest such as the Left Atrial Appendage were not mentioned)

Left Atrial Appendage (LAA)

In a study of nearly 4,000 A-Fib patients that looked at redo procedures for paroxysmal, persistent and long-term persistent A-Fib, 27% had LAA firing (the LAA is the source of arrhythmia), much more in the long-term persistent (58%) compared to paroxysmal (18%). Most wound up having a LAA isolation procedure. (Many centers, as part of their protocol, now routinely first look at the LAA after isolating the PVs. See Bordeaux Five-Step Ablation Protocol for Chronic A-Fib.)

Age Dependent

Paroxysmal patients over 80 years old had many more non-PV triggers than other patients.

Recurrence Associated with Predominately Non-PV Triggers

In a study of 197 paroxysmal A-Fib patients from 2009 to 2012 using irrigated tip RF catheters and extraostial PV isolation, there were non-PV triggers in 23.7% of patients. In patients who had recurrence, 70.8% had non-PV triggers.

 In patients who had recurrence, 70.8% had non-PV triggers.

Editor’s Comments:
Dr. Reddy’s research is important for EPs who will now look more closely at areas like the Carina and the Left Atrial Appendage to find and ablate/isolate non-PV triggers.
What does Dr. Reddy’s research mean for patients? Since 23% of A-Fib ablation triggers are found in other areas of the heart than the pulmonary veins, a simple Pulmonary Vein Isolation (PVI) or Maze surgery may not be enough to cure your A-Fib.
One of the most important findings of Dr. Reddy’s research is that recurrence (a failed ablation) is most often associated with non-PV triggers (70.8%). When searching for the right Electrophysiologist (EP) to do your ablation, they have to have experience in tracking down these non-PV triggers. When interviewing EPs, maybe one of the questions needs to be “How often do you find non-PV triggers? How do you track them down and ablate them?”
You should probably avoid any EP who only isolates the PVs. [I’ve read Operating Room reports from EPs who only do a PVI, never look for non-PV triggers, and don’t terminate the A-Fib by ablation. Instead they shock the patients back into sinus rhythm, then load them up with powerful but toxic antiarrhythmic meds like amiodarone. This usually doesn’t work.)
If you are considering (Wolf) Mini-Maze surgery, be aware that most Mini-Maze surgeries only isolate the PVs. Your chances of having non-PV triggers which a Mini-Maze surgery will not ablate/isolate are approximately 23%. That translates to at least a 23% chance of failure.
If you have non-PV triggers or A-Fib/Flutter coming from the right atrium, most Maze surgeries won’t make you A-Fib free. Surgeons currently do not access the right atrium during most Maze surgeries. To take care of these other A-Fib spots, you will have to schedule a catheter ablation.
References for this article

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Last updated: Friday, August 28, 2015 

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