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Curing Long-standing Persistent A-Fib: Ablating the Left Atrial Appendage is Key

Patients with long-standing Atrial Fibrillation are often the hardest to make A-Fib free. Because of having been in A-Fib for so long, they may have developed many A-Fib producing spots in their heart besides in the Pulmonary Veins (PVs).

Patients with long-standing Atrial Fibrillation are often the hardest to make A-Fib free

To make them A-Fib free, the electrophysiologist (EP) must ablate (isolate) not only the Pulmonary Veins, but also many non-PV triggers. Isolating the Left Atrial Appendage (LAA) significantly increased the success of catheter ablation in long-standing persistent A-Fib patients.

BELIEF Trial—LAA Isolation 76% Success Rate

In a randomized study (BELIEF trial), 173 patients with persistent A-Fib either received standard ablation plus LAA isolation or standard ablation alone. (If patients continued to have A-Fib, they could have a repeat ablation which included LAA isolation.)

At 2 years, 76% of patients who had received standard ablation plus LAA isolation were free of arrhythmia vs 56% of patients who had received only a standard ablation.

Dr. Luigi Di Biase, who presented the findings at the European Society of Cardiology 2015 Congress, stated “We do believe (LAA isolation) should be the standard of care in patients with longstanding AF.

Isolating the LAA improved long-term freedom from persistent A-Fib.

But 52% Had Impaired LAA Function

Isolating the LAA can cause problems. If many burns have to be made at the LAA to achieve isolation, they may reduce the ability of the LAA to contract properly.

In this study, 52% had impaired function, including slow LAA peak-flow velocity. In these cases, patients have to stay on anticoagulants or have their LAA closed off to prevent clots from forming in the LAA because of low blood flow.

Left Atrial Appendage heart illustration

Source: Boston Scientific Inc. used with permission

Left Atrial Appendage (LAA) Very Important When Ablating A-Fib

Dr. Gerhard Hindricks (University of Leipsig, Germany) stated:

“Should LAA isolation be recommended as an integral part of catheter ablation of longstanding atrial fibrillation? No. Further studies are necessary before such a recommendation.”

But the results of the BELIEF trial indicate just the opposite. Anyone ablating patients with persistent A-Fib must now look at the LAA to see if it is producing A-Fib signals. This is an area in the heart far too few EPs map and ablate on a routine basis.

Even when doing a paroxysmal A-Fib ablation, non-PV triggers should be mapped and ablated in the LAA. This is already part of the protocols for many Master A-Fib Ablationists. See A-Fib Producing Spots Outside the Pulmonary Veins

What Patients Need to Know: Losing LAA Contraction May be Worth It

Sometimes in longstanding persistent cases, the only way to ablate all potentials and make someone A-Fib free is to partially or completely electrically isolate the LAA from the rest of the left atrium. This may compromise the ability of the LAA to contract properly. But sometimes that’s the price that must be paid to be A-Fib free.

Serious athletes would probably miss the reduced blood flow from the left atrium. But most aging longstanding persistent A-Fib patients would hardly notice.

It’s not the end of the world to have reduced function of the LAA. Anticoagulants can help to prevent a clot from forming due to the reduced blood flow in the LAA. (50% of the patients in this study had to stay on anticoagulants anyway, because of high CHADS2 scores.)

Or the LAA can be closed off or removed by devices such as the Watchman, lariat II or AtriClip (surgery).

Serious athletes would probably miss the reduced blood flow from the left atrium. But most aging longstanding persistent A-Fib patients would hardly notice that their LAA was gone.

Anyone with persistent long-standing A-Fib should be made aware of the risk of losing one’s Left Arial Appendage function because of an ablation. But losing the LAA is a reasonable price to pay for being A-Fib free.

References for this article

Thanks to Jeffrey Patten for calling our attention to this research.

Busko, Marlene. BELIEF: Isolating Left Atrial Appendage May Halt Persistent AF. The Medscape Cardiology. August 31, 2015.

Dr. Luigi Di Biase is with Montefiore-Albert Einstein Center for Heart & Vascular Care, New York, and Texas Arrhythmia Institute at St David’s Medical Center, Austin

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