Elsevier

The Lancet

Volume 380, Issue 9852, 27 October–2 November 2012, Pages 1509-1519
The Lancet

Series
Catheter ablation of atrial arrhythmias: state of the art

https://doi.org/10.1016/S0140-6736(12)61463-9Get rights and content

Summary

Catheter ablation is at the forefront of the management of a range of atrial arrhythmias. In this Series paper, we discuss the underlying mechanisms and the current role of catheter ablation for the three most common atrial arrhythmias encountered in clinical practice: focal atrial tachycardia, atrial flutter, and atrial fibrillation. The mechanisms of focal atrial tachycardia and atrial flutter are well understood, and these arrhythmias are amenable to curative catheter ablation with high success rates. In most cases, paroxysmal atrial fibrillation is initiated by triggers located within pulmonary vein musculature. Circumferential ablation to isolate this musculature is associated with high success rates for elimination of paroxysmal atrial fibrillation in selected populations. Because of the problem of recurrent pulmonary vein connection, more than one procedure will be needed in about 30% of patients, and new technologies are being developed to reduce this occurrence. The mechanisms that sustain persistent atrial fibrillation are not well understood and are the subject of continuing investigation. As such, ablation approaches and technologies for this arrhythmia are still evolving.

Introduction

Atrial arrhythmias include a range of different rhythm disturbances that encompass almost the full range of arrhythmia mechanisms. The three most frequently encountered arrhythmias, which are the focus of this review, are focal atrial tachycardia, atrial flutter, and atrial fibrillation. Generally, these arrhythmias respond poorly to antiarrhythmic drugs, and patients frequently have recurring and at times debilitating symptoms. Throughout the past decade, major technological advances in cardiac electrophysiology have brought catheter ablation to the forefront of treatment algorithms for these arrhythmias. In this Series paper, we provide an overview of the underlying mechanisms, relevant anatomy, and catheter-based treatment of these arrhythmias.

Section snippets

Classification of atrial arrhythmias

The nomenclature surrounding the classification of atrial arrhythmias continues to be unclear. Broadly, organised atrial tachycardias can be classified into two categories according to the arrhythmia mechanism: focal or macro-re-entry. Atrial fibrillation is a disorganised rhythm and its classification according to underlying mechanism is still evolving.

Focal atrial tachycardias are defined by early atrial activation from a discrete site with radial spread to the periphery.1 They can be

ECG considerations

ECG cannot reliably distinguish tachycardia mechanism. No effective rate cutoff exists to differentiate focal atrial tachycardia from atrial flutter, and when viewing a 12-lead ECG snapshot, it can be difficult to distinguish between atrial fibrillation with coarse fibrillatory waves and atrial flutter. The distinction can be made with a careful analysis of P wave morphology and rate, which should be constant in atrial flutter and variable in atrial fibrillation.

General considerations

Focal atrial tachycardia is classified as a type of supraventricular tachycardia. It is the least common form of this arrhythmia (after atrioventricular node re-entry and atrioventricular re-entry tachycardia) and accounts for just 10–15% of patients referred for catheter ablation of supraventricular tachycardia.4 Although generally benign, up to 25% of patients will present with frequent paroxysms or incessant activity, with a third of these patients eventually developing a

General considerations

Atrial flutter represents a heterogeneous group of arrhythmias defined mechanistically by the presence of a large circuit around a central obstacle, which can be a fixed anatomical structure or a functional electrophysiological line of block. Generally, the unique anatomy of the atrium is an important determinant of the location of a flutter circuit. The most common form is best known as typical atrial flutter and is characterised by the presence of classic saw-tooth flutter waves in the

General considerations

Over the past decade, catheter ablation has evolved to become a routine procedure for selected patients with atrial fibrillation. This section will focus on the underlying mechanisms of atrial fibrillation in the context of catheter ablation, the common techniques, and the outcomes of these techniques.

Guidelines from the American College of Cardiology, American Heart Association, and European Society of Cardiology recommend catheter ablation for patients with atrial fibrillation who remain

Conclusion

Catheter ablation is now at the forefront of the treatment algorithm for a broad range of atrial arrhythmias. In patients with focal atrial tachycardia and typical atrial flutter, it is a first line therapy with efficacy in excess of 90%. For patients with a range of complex atypical flutters, it is a highly effective approach in those not readily controlled with antiarrhythmic drugs. For patients with previous atrial surgery or more complex congenital heart disease, late flutter recurrence or

Search strategy and selection criteria

We searched PubMed for reports published between 1980, and 2012, with the search terms “atrial fibrillation”, “atrial flutter”, and “atrial tachycardia” in combination with the term “ablation”. We mainly selected publications from the past 5 years, but did not exclude frequently referenced and highly regarded older publications. We also pursued articles referenced in primary sources and their relevant citations and selected those we judged relevant.

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