Catheter Ablation of Atrial Fibrillation E-Book

Etienne Aliot

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 606

Veröffentlichungsjahr: 2011

Beschreibung

Catheter Ablation of Atrial Fibrillation Edited by Etienne Aliot, MD, FESC, FACC, FHRS Chief of Cardiology, Hôpital Central, University of Nancy, France Michel Haïssaguerre, MD Chief of Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, France Warren M. Jackman, MD Chief of Electrophysiology, University of Oklahoma Health Science Center, USA In this text, internationally recognized authors explore and explain the advances in basic and clinical electrophysiology that have had the greatest impact on catheter ablation of atrial fibrillation (AF). Designed to assist in patient care, stimulate research projects, and continue the remarkable advances in catheter ablation of AF, the book covers: * the fundamental concepts of AF, origin of signals, computer simulation, and updated reviews of ablation tools * the present practical approaches to the ablation of specific targets in the fibrillating atria, including pulmonary veins, atrial neural network, fragmented electrograms, and linear lesions, as well as the strategies in paroxysmal or chronic AF or facing left atrial tachycardias * the special challenge of heart failure patients, the impact of ablation on mortality, atrial mechanical function, and lessons from surgical AF ablation Richly illustrated by numerous high-quality images, Catheter Ablation of Atrial Fibrillation will help every member of the patient care team.

Leseprobe

Contents

Contributors

Introduction

Part 1 Fundamental concepts of atrial fibrillation

1 Anatomy of the left atrium relevant to atrial fibrillation ablationJosé Angel Cabrera, Jerónimo Farré, Siew Yen Ho, Damián Sánchez-Quintana

Introduction

Components of the left atrium

The walls of the left atrium and the septum

Pulmonary veins and their ending into the left atrium

Gross anatomy of the left posterolateral ridge

Gross anatomy of the left atrial appendage

Architecture of the left posterolateral ridge: the Marshall structures

The left atrial isthmus

Architecture of the PV-atrial junction and left posterior atrial wall: relevance to atrial fibrillation ablation

The coronary sinus

The esophagus and other extracardiac structures

Left atrial autonomic nervous system content

Conclusion

References

2 Mechanisms and significance of fractionated electrograms recorded during atrial fibrillationSander Verheule, Els Tuyls, Natasja de Groot, Maurits Allessie

Historical perspective

Electrogram fractionation and discontinuous conduction

Relation between electrogram fractionation and activation pattern

Regional distribution of atrial fractionated electrograms

Practical applications of fractionated electrogram recording

References

3 Computer simulation studies of atrial fibrillationNathalie Virag, Lam Dang, Patrick Ruchat, Juerg Schlaepfer, Lukas Kappenberger

Introduction

From magnetic resonance images to a computer model of atrial fibrillation

Propagation of atrial activation

Simulation of atrial fibrillation

Simulation of therapies for atrial fibrillation

Systematic evaluation of ablation patterns

Evaluation of the effect of non-transmural ablation lines

Evaluation of hybrid therapies for atrial fibrillation

Conclusion

Acknowledgments

References

4 Experimental and theoretical insights into fundamental mechanisms of antiarrhythmic drug actions on atrial fibrillation: prospects for improved pharmacotherapyStanley Nattel

Introduction

Classical antiarrhythmic drug therapy for sinus rhythm maintenance

Present status of antiarrhythmic drug therapy

Approaches to developing new anti-atrial fibrillation drugs

Conclusion

References

5 Mechanisms of atrial fibrillation in animals and humansOmer Berenfeld, Jérôme Kalifa, José Jalife

Introduction

Acute atrial fibrillation: the sheep heart model

Fibrillatory propagation and the atrial structure

Fibrillatory propagation and dispersion of action potential duration

Fibrillatory conduction and fractionation

Spatial distribution of dominant frequencies during atrial fibrillation in patients

High dominant frequency sites and maintenance of atrial fibrillation

Activation frequency and driver mechanisms

Conclusion

Acknowledgements

References

6 Three-dimensional images in catheter ablation of atrial fibrillationHsuan-Ming Tsao, Mei-Han Wu, Shih-Ann Chen

Introduction

Anatomic characteristics of the pulmonary veins and left atrium

Anatomic structures surrounding the left atrium (Table 6.2)

Morphological remodeling of the pulmonary veins and left atrium in atrial fibrillation patients

Detection of complications after catheter ablation

Delineation of the right atrial structure and superior vena cava

Conclusion

References

7 Signal processing of fibrillatory electrogramsThomas H. Everett, IV, Jeffrey E. Olgin

Introduction

The basics of signal processing

Signal analysis

Results from experimental data

Signal analysis in clinical data

The future of signal processing

References

Part 2 Practical approaches in atrial fibrillation

8 Emerging technologies in the treatment of atrial fibrillationMatthew Wright, Christian de Chillou, Etienne Aliot, D. Wyn Davies

Introduction

Current ablation techniques and results

Emerging ablation technologies

Emerging navigation and mapping technologies

Carto™ and NavX™/Ensite™

Conclusion

References

9 Techniques targeting the pulmonary veinsSabine Ernst, Feifan Ouyang, Matthias Antz, Julian K. R. Chun, Dietmar Bänsch, Karl-Heinz Kück

Introduction

Rational for targeting the pulmonary veins

Critical review of different techniques targeting the pulmonary veins

New tools for ablation

Conclusion

References

10 Techniques of linear lesion for atrial fibrillation ablationMélèze Hocini, Kang Teng Lim, Prashanthan Sanders, Pierre Jaïs, Mark D. O’Neill, Yoshihide Takahashi, Anders Jönsson, Seiichiro Matsuo, Sébastien Knecht, Leonardo Arantès, Jacques Clémenty, Michel Haïssaguerre

Introduction

Pulmonary vein ablation

Indications for linear lesion

Technical approach to linear ablation

Post-ablation management

Left atrial linear ablation for substrate modification

Conclusion

References

11 Ablation strategies in paroxysmal atrial fibrillationIsabel Deisenhofer, Claus Schmitt

Introduction

Focal approaches to ablate paroxysmal atrial fibrillation using global mapping tools

Strategies focusing on the pulmonary veins

Ablation of fractionated potentials and autonomic nerves

Combined approaches

Conclusion

References

12 Ablation strategies in chronic atrial fibrillationMark D. O’Neill, Kang Teng Lim, Pierre Jaïs, Mélèze Hocini, Yoshihide Takahashi, Anders Jönsson, Frédéric Sacher, Prashanthan Sanders, Sathish Kodali, Leonardo Arantès, Seiichiro Matsuo, Sébastien Knecht, Thomas Rostock, Martin Rotter, Jacques Clémenty, George J. Klein, Michel Haïssaguerre

Introduction

Definition of atrial fibrillation

Surgical origins of catheter ablation strategies for atrial fibrillation

From linear ablation to pulmonary vein isolation

Expansion of left atrial targets in chronic atrial fibrillation

Results of techniques incorporating novel ablation targets

Stepwise ablation approach for chronic atrial fibrillation

Technique of stepwise ablation

The importance of discrete anatomic sites for termination of atrial fibrillation

Cumulative benefits of the stepwise approach

Atrial fibrillation inducibility testing

Acute procedural outcome

Arrhythmia recurrence post catheter ablation

Effects of catheter ablation on atrial electrical and mechanical properties

Factors predictive of procedural AF termination

Future directions for ablation of chronic atrial fibrillation

Conclusion

References

Part 3 Special challenges in atrial fibrillation

13 Diagnostic algorithm of atrial tachycardia following atrial fibrillation ablation: importance of localized reentries, 193Pierre Jaïs, Sébastien Knecht, Seiichiro Matsuo, Mark D. O’Neill, Rajesh Subbiah, Leonardo Arantès, Kang Teng Lim, Nicolas Derval, Frédéric Sacher, Antoine Deplagne, Pierre Bordachar, Mélèze Hocini, Jacques Clémenty, Michel Haïssaguerre

Introduction

Definitions

Mechanisms

Differentiation

Localization of atrial tachycardias

Technical aspects of atrial tachycardia mapping and ablation

Algorithm and ablation results

Conclusion

Acknowledgments

References

14 Catheter ablation of atrial fibrillation in patients with heart failureIbrahim Abu Romeh, Mohammed Nasir Khan, Andrea Natale

Introduction

Atrial fibrillation and heart failure: mechanisms

Atrial fibrillation and congestive heart failure: treatment

Conclusion

References

15 Morbidity and mortality of ablation versus drugsCarlo Pappone, Vincenzo Santinelli

Introduction

The need for sinus rhythm maintenance in patients with atrial fibrillation

Pharmacological or transcutaneous radiofrequency ablation therapy for rhythm control?

Efficacy: trials comparing atrial fibrillation ablation strategy versus antiarrhythmic drug therapy

Morbidity: atrial fibrillation ablation strategy versus antiarrhythmic drug therapy

Mortality: atrial fibrillation ablation strategy versus antiarrhythmic drug therapy

Conclusion

References

16 Atrial mechanical function after atrial fibrillation ablationPrashanthan Sanders, Pierre Jaïs, Glenn D. Young, Frédéric Sacher, Martin Rotter, Mélèze Hocini, Li-Fern Hsu, Martin K Stiles, Bobby John, Dennis H. Lau, Yoshihide Takahashi, Thomas Rostock, Pawel Kuklik, Lorraine Mackenzie, Scott Willoughby, Michel Haïssaguerre

Atrial fibrillation and stroke risk

Anticoagulation in atrial fibrillation

Tachycardia-mediated atrial cardiomyopathy

Clinical characterization of atrial mechanical function

Atrial mechanical dysfunction after cardioversion

Potential detrimental effect of ablation on atrial mechanical function

Atrial mechanical function after atrial fibrillation ablation

Risk of stroke post atrial fibrillation ablation

Conclusion

Acknowledgments

References

17 Surgery for atrial fibrillation: from scalpel to catheter … and back?Fiorenzo Gaita, Antonio Montefusco, Domenico Caponi, George J. Klein

Introduction

Electrophysiology of atrial fibrillation

Surgical ablation: 20 yearsߣ evolution

Operative therapy after the maze and corridor procedures

Ablative tools

Conclusion

References

18 Electrogram-guided approach to ablation of atrial fibrillationDavid J. Wilber, Joseph Akar, Peter Santucci, Neil Brysiewicz

Introduction

Genesis and significance of fractionated atrial electrograms

Targeting complex fractionated atrial electrograms as a primary ablation strategy

Targetting complex fractionated atrial electrograms as an adjunct ablation strategy

Targetting complex fractionated atrial electrograms as an adjunct ablation strategy

Approach to electrogram-guided ablation

Acknowledgments

References

Index

© 2008 by Blackwell PublishingBlackwell Futura is an imprint of Blackwell Publishing

Blackwell Publishing, Inc., 350 Main Street, Malden, Massachusetts 02148-5020, USABlackwell Publishing Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UKBlackwell Publishing Asia Pty Ltd, 550 Swanston Street, Carlton, Victoria 3053, Australia

All rights reserved. No part of this publication may be reproduced in any form or by any electronic or mechanical means, including information storage and retrieval systems, without permission in writing from the publisher, except by a reviewer who may quote brief passages in a review.

First published 20081 2008

ISBN: 978-1-4051-6349-1

Library of Congress Cataloging-in-Publication Data

Catheter ablation of atrial fibrillation / edited by Etienne Aliot, Michel Haissguerre, Warren M. Jackman.p. ; cm.Includes bibliographical references.ISBN 978-1 -4051 -6349- 1 (Hbk trade version)978-1-4051-8665-0 (Customised version, not for trade sale)1. Catheter ablation. 2. Atrial fibrillation - Surgery. I. Aliot, Etienne. II. Ha?ssaguerre, Michel. III. Jackman,Warren M.[DNLM: 1. Atrial Fibrillation - surgery. 2. Atrial Fibrillation - therapy. 3. Catheter Ablation - methods. WG 330 C3628 2008]

RD598.35.C39C383 2008616.1′28-dc222007049865

A catalogue record for this title is available from the British Library

Commissioning Editor: Gina AlmondDevelopment Editor: Beckie BrandEditorial Assistant: Jamie Hartmann-BoyceProduction Controller: Debbie Wyer

For further information on Blackwell Publishing, visit our website:www.blackwellcardiology.com

The publisher’s policy is to use permanent paper from mills that operate a sustainable forestry policy, and which has been manufactured from pulp processed using acid-free and elementary chlorine-free practices. Furthermore, the publisher ensures that the text paper and cover board used have met acceptable environmental accreditation standards.

Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The Publisher is not associated with any product or vendor mentioned in this book.

The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by physicians for any particular patient. The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. Readers should consult with a specialist where appropriate. The fact that an organization or Website is referred to in this work as a citation and/or a potential source of further information does not mean that the author or the publisher endorses the information the organization or Website may provide or recommendations it may make. Further, readers should be aware that Internet Websites listed in this work may have changed or disappeared between when this work was written and when it is read. No warranty may be created or extended by any promotional statements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom.

Contributors

Joseph Akar, MD, PHDCenter for Heart and Cardiovascular Medicine,Loyola University Health System,Maywood, Illinois, USA

Etienne Aliot, MDDepartment of Cardiology,University of Nancy,Vandoeuvre les Nancy,France

Maurits Allessie, MD, PhDDepartment of Physiology,Cardiovascular Research Institute Maastricht (CARIM),Maastricht University, Maastricht,The Netherlands

Matthias Antz, MDOberärztin Magn. Navigation,Hanseatic Heart Center St. Georg,Hamburg, Germary

Leonardo Arantès, MDHôpital Cardiologique du Haut-Lévêque and theUniversité Victor Segalen Bordeaux II,Bordeaux, France

Dietmar Bänsch, MDOberärztin Magn. Navigation,Hanseatic Heart Center St. Georg,Hamburg, Germany

Omer Berenfeld, PHDDepartment of Pharmacology and the Institute forCardiovascular Research,SUNY Upstate Medical University,Syracuse, New York, USA

Pierre Bordachar, MDHôpital Cardiologique du Haut-Lévêque and theUniversité Victor SegalenBordeaux II, Bordeaux, France

Neil Brysiewicz, BSECenter for Heart and Cardiovascular Medicine,Loyola University Health System,Maywood, Illinois, USA

José Angel Cabrera, MD, PhDArrhythmia Unit, Hospital Quiron-Madrid,Universidad Europea de Madrid,Madrid, Spain

Domenico Caponi, MDCardinal Massaia Hospital,Asti, AT Italy

Shih-Ann Chen, MDDivision of Cardiology and Cardiovascular ResearchCenter, National Yang-Ming University, School ofMedicine and Taipei Veterans General Hospital,Taiwan

Julian K.R. Chun, MDOberärztin Magn. Navigation,Hanseatic Heart Center St. Georg,Hamburg, Germany

Jacques Clémenty, MDHôpital Cardiologique du Haut-Lévêque and theUniversité Victor Segalen Bordeaux II,Bordeaux, France

Lam Dang, PHDSwiss Federal Institute of Technology,Lausanne, Switzerland

D. Wyn Davies, MD, FRCPSt. Mary’s Hospital,Waller Department of Cardiology,London, UK

Christian de Chillou, MD, PHDDepartment of Cardiology,Nancy University Hospital, Nancy, France

Natasja de Groot, MD, PHDDepartment of Physiology,Cardiovascular Research Institute Maastricht (CARIM),Maastricht University, Maastricht,The Netherlands

Isabel Deisenhofer, MDDeutsches Herzzentrum München,Klinik an der Technischen,Universität München,München, Germany

Antoine Deplagne, MDHôpital Cardiologique du Haut-Lévêque and the UniversitéVictor Segalen Bordeaux II,Bordeaux, France

Nicolas Derval, MDHôpital Cardiologique du Haut-Lévêque and theUniversité Victor Segalen Bordeaux II,Bordeaux, France

Sabine Ernst, MD, PHDImperial College,National Heart and Lung Institute,Royal Brompton and Harefield Hospital,London, UK

Thomas H. Everett, IV, PhDDivision of Cardiology and the CardiovascularResearch Institute, University of CaliforniaSan Francisco, San Francisco,California, USA

Jerónimo Farré, MD, PhD, FESCDepartment of Cardiology,Fundación Jiménez Díaz-Capio,Universidad Autónoma de Madrid,Madrid, Spain

Fiorenzo Gaita, MDDepartment of Cardiology,Cardinal Massaia Hospital, Asti,AT, Italy

Michel Haïssaguerre, MDHôpital Cardiologique du Haut-Lévêque and theUniversité Victor Segalen Bordeaux II,Bordeaux, France

Siew Yen Ho, PhD, FRCPathNational Heart and Lung Institute,Imperial College and the Royal Brompton andHarefield NHS Trust,London, UK

Mélèze Hocini, MDHôpital Cardiologique du Haut-Lévêque and theUniversité Victor Segalen Bordeaux II,Bordeaux, France

Li-Fern Hsu, MB, BSHôpital Cardiologique du Haut-Lévêque and theUniversité Victor Segalen Bordeaux II,Bordeaux, France

Pierre Jaïs, MDHôpital Cardiologique du Haut-Lévêque and theUniversité Victor Segalen Bordeaux II,Bordeaux, France

José Jalife, MDDepartment of Pharmacology and Institute forCardiovascular Research,SUNY Upstate Medical University,Syracuse, New York, USA

Bobby John, MDCardiovascular Research Centre,Department of Cardiology,Royal Adelaide Hospital and the Disciplines ofMedicine and Physiology, University of Adelaide,Adelaide, Australia

Anders Jönsson, MDHôpital Cardiologique du Haut-Lévêque and theUniversité Victor Segalen Bordeaux II,Bordeaux, France

Jérôme Kalifa, MD, PhDDepartment of Pharmacology and Institute forCardiovascular Research,SUNY Upstate Medical University,Syracuse, New York, USA

Lukas Kappenberger, MDCardioMet, Centre Hospitalier Universitaire Vaudois,Lausanne, Switzerland

Mohammed Nasir Khan, MDCardiovascular Associates,Elk Grove Village,Illinois, USA

George J. Klein, MDUniversity of Western Ontario, University Hospital,London, Ontario, Canada

Sébastien Knecht, MDHôpital Cardiologique du Haut-Lévêque and theUniversité Victor Segalen Bordeaux II,Bordeaux, France

Sathish Kodali, MDHôpital Cardiologique du Haut-Lévêque and theUniversité Victor Segalen Bordeaux II,Bordeaux, France

Karl-Heinz Kück, MDOberärztin Magn. Navigation,Hanseatic Heart Center St. Georg,Hamburg, Germany

Pawel Kuklik, BSCCardiovascular Research Centre, Department ofCardiology, Royal Adelaide Hospital and theDisciplines of Medicine and Physiology,University of Adelaide,Adelaide, Australia

Dennis H. Lau, MB, BSCardiovascular Research Centre,Department of Cardiology,Royal Adelaide Hospital and the Disciplines ofMedicine and Physiology, University of Adelaide,Adelaide, Australia

Kang Teng Lim, MB, BSHôpital Cardiologique du Haut-Lévêque and theUniversité Victor Segalen Bordeaux II,Bordeaux, France

Lorraine Mackenzie, PHDCardiovascular Research Centre,Department of Cardiology,Royal Adelaide Hospital and the Disciplines ofMedicine and Physiology, University of Adelaide,Adelaide, Australia

Seiichiro Matsuo, MDHôpital Cardiologique du Haut-Lévêque and theUniversité Victor Segalen Bordeaux II,Bordeaux, France

Antonio Montefusco, MDCardinal Massaia Hospital,Asti, AT, Italy

Andrea Natale, MDAdjunct Professor,Stanford University, Palo Alto,California, USA

Stanley Nattel, MDDepartment of Medicine and Research Center, MontrealHeart Institute and Université de Montréaland Department of Pharmacology and Therapeutics,McGill University, Montreal,Quebec, Canada

Jeffrey E. Olgin, MDDivision of Cardiology and the Cardiovascular ResearchInstitute, University of CaliforniaSan Francisco, San Francisco, California, USA

Mark D. O’Neill, MB, bch, dphilHôpital Cardiologique du Haut-Lévêque and theUniversité Victor Segalen Bordeaux II, Bordeaux, France

Feifan Ouyang, MDOberärztin Magn. Navigation,Hanseatic Heart Center St. Georg,Hamburg, Germany

Carlo Pappone, MD, PHDDepartment of Cardiology,Electrophysiology and Cardiac Pacing Unit,San Raffaele Scientific Institute,Milan, Italy

Ibrahim Abu Romeh, MDHeart Failure and Transplant Fellow,University of Utah,Utah, USA

Thomas Rostock, MDHôpital Cardiologique du Haut-Lévêque and theUniversité Victor Segalen Bordeaux II,Bordeaux, France

Martin Rotter, MDHôpital Cardiologique du Haut-Lévêque and theUniversité Victor Segalen Bordeaux II,Bordeaux, France

Patrick Ruchat, MDService de Chirurgie Cardio-Vasculaire,Centre Hospitalier Universitaire Vaudois,Lausanne, Switzerland

Frédéric Sacher, MDHôpital Cardiologique du Haut-Lévêque and theUniversité Victor Segalen Bordeaux II,Bordeaux, France

Damián Sánchez-Quintana, MD, PHDDepartment of Human Anatomy and Cell Biology,Faculty of Medicine, University of Extremadura,Badajoz, Spain

Prashanthan Sanders, MB, BS, PHDHôpital Cardiologique du Haut-Lévêque and theUniversité Victor Segalen Bordeaux II,Bordeaux, France and Cardiovascular Research Centre,Department of Cardiology, Royal Adelaide Hospital andthe Disciplines of Medicine and Physiology,University of Adelaide,Adelaide, Australia

Vincenzo Santinelli, MDDepartment of Cardiology,Electrophysiology and Cardiac Pacing Unit,San Raffaele Scientific Institute,Milan, Italy

Peter Santucci, MDCenter for Heart and Cardiovascular Medicine,Loyola University Health System,Maywood, Illinois, USA

Juerg Schlaepfer, MDService de Cardiologie,Centre Hospitalier Universitaire Vaudois,Lausanne, Switzerland

Claus Schmitt, MDMedizinischen Klinik,Klinikum Karlsruhe,Karlsruhe, Germany

Martin K. Stiles, MB, CHBCardiovascular Research Centre,Department of Cardiology,Royal Adelaide Hospital and the Disciplines ofMedicine and Physiology, University of Adelaide,Adelaide, Australia

Rajesh Subbiah, BSC(med), MB, BS, PHDHôpital Cardiologique du Haut-Lévêque and theUniversité Victor Segalen Bordeaux II,Bordeaux, France

Yoshihide Takahashi, MDHôpital Cardiologique du Haut-Lévêque and theUniversité Victor Segalen Bordeaux II,Bordeaux, France

Hsuan-Ming Tsao, MD

Department of Internal Medicine, National Yang-MingUniversity Hospital, Taiwan

Els Tuyls, MScDepartment of Physiology,Cardiovascular Research Institute Maastricht (CARIM),Maastricht University,Maastricht, The Netherlands

Sander Verheule, PhDDepartment of Physiology, Cardiovascular ResearchInstitute Maastricht (CARIM),Maastricht University, Maastricht,The Netherlands

Nathalie Virag, PhDMedtronic Europe,Tolochenaz, Switzerland

David J. Wilber, MDCenter for Heart and Cardiovascular Medicine,Loyola University Health System,Maywood, Illinois, USA

Scott Willoughby, PHDCardiovascular Research Centre, Department ofCardiology, Royal Adelaide Hospitaland the Disciplines of Medicine and Physiology,University of Adelaide,Adelaide, Australia

Matthew Wright, MBBS, PHDSt. Mary’s Hospital,Waller Department of Cardiology,London, UK

Mei-Han Wu, MDDivision of Radiology, National Yang-Ming University,School of Medicine and Taipei Veterans General Hospital,Taiwan

Glenn D. Young, MB, BSCardiovascular Research Centre,Department of Cardiology,Royal Adelaide Hospital and the Disciplines ofMedicine and Physiology,University of Adelaide,Adelaide, Australia

Introduction

Atrial fibrillation (AF) has long been a field for experimental, pharmacological, and clinical investigations. After initial surgical attempts to cure AF using multiple incisions, the observation that the pulmonary veins were mainly involved in the genesis of AF has promoted the use of catheter techniques for curative approaches.

This book provides a collective text that integrates advances in basic and clinical electrophysio-logy that have emerged in the last 10 years. Our goal is to produce a treatise that electrophysiologists, allied healthcare professionals, and industry personnel will use as a guide to assist in patient care, to stimulate research projects, and to continue the remarkable advances in the treatment of AF.

A major message appears to be the complexity of underlying factors initiating and perpetuating AF, and the need for combined approaches to involve these different mechanisms. Another message is to acknowledge the limitations of present technologies which, despite achieving dramatic termination of most AF, require additional interventions for tissue recovery or new substrate.

The book is divided into several parts. The first part (Chapters 1–7) is devoted to the fundamental concepts of AF, origin of signals, computer simulation, and updated reviews of ablation tools. The anatomy chapter is richly illustrated by numerous high quality images. This information is necessary for appropriate clinical practice. The second part (Chapters 8–12) provides the present practical approaches to the ablation of specific targets in the fibrillating atria including pulmonary veins, fragmented electrograms, and linear lesions and details the strategies in paroxysmal or chronic AF or facing left atrial tachycardias. The final part (Chapters 13–18) addresses the special challenge of heart failure patients, the impact of ablation on mortality, atrial mechanical function, and lessons from surgical AF ablation.

Each chapter is written by experienced and internationally recognized authors, most being the leading experts in this field.

We hope that this book may become a reference text for many and will be followed by future editions to provide up to date information in this rapidly developing area.

Etienne AliotMichel HaïssaguerreWarren M. Jackman

PART 1

Fundamental concepts of atrial fibrillation

CHAPTER 1

Anatomy of the left atrium relevant to atrial fibrillation ablation

José Angel Cabrera, Jerónimo Farré, Siew Yen Ho, Damián Sánchez-Quintana

Introduction

Atrial fibrillation (AF) is an arrhythmia most likely due to multiple etiopathogenic mechanisms. In spite of a still incomplete understanding of the anatomo-functional basis for the initiation and maintenance of AF, various radiofrequency catheter ablation (RFCA) techniques have been shown to modify the substrate of the arrhythmia and/or its neurovegetative modulators, achieving in a high proportion of cases a sustained restoration of a stable sinus rhythm [1–26]. Catheter ablation techniques in patients with AF have evolved from an initial approach focused on the pulmonary veins (PVs) and their junctions with the left atrium (LA), to a more extensive intervention mainly, but not exclusively, on the left atrial myocardium and its neurovegetative innervation [27–32]. We firmly believe that progress is still required to refine the currently accepted catheter ablation approaches to AF. Because the LA is the main target of catheter ablation in patients with AF, in this chapter we review the gross morphological and architectural features of this chamber and its relations with extracardiac structures. The latter have also become relevant because of some extracardiac complications of AF ablation, such as injuries of the phrenic and vagal plexus nerves, or the devastating left atrioesophageal fistula formation [33–40].

Components of the left atrium

From a gross anatomical viewpoint the LA has four components: (1) a venous part that receives the PVs; (2) a vestibule that conducts to the mitral valve; (3) the left atrial appendage (LAA); and (4) the so-called interatrial septum. We want to emphasize that the true interatrial septum is the oval fossa, a depression in the right atrial aspect of the area traditionally considered to be the interatrial septum [41–46] (Figures –). At the left atrial level, a membranous valve covers this region and conceptually represents the only true interatrial septum in the sense that it can be crossed without exiting the heart. The rest of the “muscular interatrial septum” is formed by the apposition of the right and left atrial myocardia that are separated by vascularized fibro-fatty tissues extending from the extracardiac fat. This is why we prefer to use the term rather than muscular interatrial septum, a concept that is not only of academic interest because trans-septal punctures to access the LA should be performed through the oval fossa (Figure ). Thus, a puncture throughout the interatrial groove (the muscular interatrial septum) may result in hemopericardium in a highly antico-agulated patient because blood will dissect the vascularized fibro-fatty tissue that is sandwiched between the right and left atrial myocardium at this level [47–49].