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2025 AF Symposium
Challenging Cases: AF Management & Predicting the Origin of Non-PV Triggers
Dr. Francis Marchlinski
The moderator of this session Dr. David Keane, introduced Dr. Francis Marchlinski of the University of Pennsylvania, Philadelphia, PA as “no one else in the history of electrophysiology has done more to look at non-PV triggers as a grossly underappreciated potential avenue for improving the outcome of AF ablation.”
Dr. Francis Marchlinski began by talking about the case of a 74-year-old woman who developed Paroxysmal A-Fib in 2015.
Paroxysmal A-Fib: occasional attacks of A-Fib that return to normal heart rhythm on their own. Persistent Atrial Fibrillation: attacks that last more than a week, or that lasts less than a week but requires cardioversion to return to normal rhythm.
She was treated with the beta blocker Sotalol, then switched to the antiarrhythmic drugs Propafenone and Flecainide because of recurrence of her A-Fib. Later, she developed infrequent but persistent A-Fib which required cardioversions.
Paroxysmal A-Fib—One Non-PV Trigger
This lead to her first ablation. Her Pulmonary Veins (PVs) were isolated and they found one non-PV trigger in the upper Christa Terminallis area (a prominent, C-shaped ridge located on the posterolateral wall of the right atrium). Though it was documented, no action was taken about the abnormalities in the posterior wall.
She was A-Fib free for a year. Then her A-Fib returned.
Re-Do Catheter Ablation
Monitor example: Mapping of non-PV triggers: Catheter position during high-dose isoproterenol infusion.
In a re-do procedure, her PVs remained isolated, but there was extensive left atrium scarring involving the septal segment and more extensive abnormalities in the posterior wall.
The re-do ablation targeted the scar tissue (substrate) of non-PV triggers. The drug isoproterenol and burst pacing were used to induce A-Fib triggers. Ablation targeted the posterior wall and the upper septum.
The end point was her becoming A-Fib and Flutter free.
How Dr. Marchlinski Maps for Non-PV Triggers
Dr. Marchlinski described a two-catheter system and cardioversions used to develop activation algorithms to determine where to start mapping for non-PV triggers.
Two-Catheter System: One diagnostic decapolar catheter extends along the posterior right atrium into the superior vena cava and the other in the proximal coronary sinus.
The timing and activation sequence from the electrical recordings using these two catheters can point to the origin of the A-Fib triggers.
Spontaneous and/or isoproterenol induced non-PV triggers are identified after the pulmonary veins have been isolated.
Cardioversion is used to restore normal sinus rhythm in patients who are in persistent A-Fib with triggers identified with the re-initiation of A-Fib.
Algorithm Predicts Origin of Non-PV Triggers: Data from over 1,200 patients was used to create the algorithm that could predict the origin of non-PV triggers. It was also used to create a risk score for predicting which patients develop non-PV triggers (including such factors as Left atrium scar and female gender).
Patient’s A-Fib Recurs with New Scarring
Monitor example: Voltage mapping (left atrial posterior wall isolation in a paroxysmal atrial fibrillation patient).
The patient’s arrhythmia recurred 8 months later with symptomatic A-Fib and Flutter and lots of new scarring evident based on voltage mapping of the left atrium.
She expressly did not want a Watchman (a Left Atrial Appendage closure device) installed, and was also undergoing breast cancer treatment.
Using the algorithm Dr. Marchlinski’s team had developed, they were able to identify two new non-PV trigger sites which were then ablated. They also ablated a mitral annular flutter and returned her to normal sinus rhythm.
Success! Since this last procedure, she has been doing well and has been able to take care of her other medical problems without recurrence of her A-Fib.
Advice to Electrophysiologists: “Stay Calm. Stay Focused”
Dr. Marchlinski concluded by encouraging doctors to “stay calm, stay focused, examine the substrate of non-PV triggers, and create a plan for identifying the origin of these triggers.”
Editor’s Comments
Editor’s CommentsThis was one of the most complicated cases I’ve ever tried to describe. I hope I did justice to Dr. Marchlinski’s outstanding work.
Non-PV Trigger Identification and Ablation Critical for Some Patients: For too many patients, identifying and ablating non-PV triggers is a critical, necessary step in achieving freedom from A-Fib. But even for someone like Dr. Marchlinski, this isn’t easy.
Techniques to find and ablate Non-PV triggers are becoming a major focus of A-Fib research.
What This Means for A-Fib Patients: Research is continuing to develop new ways of finding and ablating Non-PV triggers.
Before having a catheter ablation for your Atrial Fibrillation, always ask your electrophysiologist (EP) how they identify non-PV trigger spots and how they ablate them.
Caution: Confirm that your EP will look for non-PV triggers, NOT just ablate your PVs and cardiovert you back into normal sinus rhythm.
