RSPV: watch out for phrenic nerve / diaphragm paralysis - paceablation catheter on upper edge of RSPV to
see if you have diaphragmatic stimulation
RIPV: watch out your lasso doesnt fall back in the mitral valve and get stuck there
Start with 7500 heparin bolus then 1400 /hr
HEPARIN PROTOCOL DURING AFA WHILE ON WARFARIN
Basically the 2 most important predictors of heparin requirement are baseline INR and body weight. So the
protocol is designed considering both.
NOACs require higher heparin to maintain the same target ACT as there is no blockade in the upstream. We
keep the same target ACTs (>350) independent of timing of stopping NOACS as our goal is complete blockage
of intrinsic pathway. So you can potentially use the same algorithm, if comfortable, independent of using
warfarin or NOACs (or the timing of stopping either of them) in the background.
HRS May 2017 issue 5 revisiting PVI for Pe AF meta analysis Voskoboynik et al Melbourne
CHASE-AF and STAR AF II randomized trials were pivotal in demonstrating that adjunctive RF ablation
strategies (lines, CFAEs) did not result in a higher freedom from arrhythmia than a PVI-only strategy using RF
but were associated with higher fluoroscopy and procedure times. Follow-up meta-analyses, which included
these 2 studies, now demonstrated no benefit in arrhythmia-free survival with LA linear ablation or CFAE
ablation in the PeAF population. Strengthening the rationale to abandon these ineffective approaches are the
considerable data demonstrating the proarrhythmic potential of these lesion sets. Recent studies examining
the role of focal impulse and rotor modulation (FIRM)-guided ablation have also yielded conflicting results.
Success rates (arrhythmia-free survival on/off antiarrhythmic drugs) as high as 70.4% at 29 months of follow-
up8 and as low as 21% at 16 months9 have been reported, and considerable debate exists. This again
underscores that at present no strategy is proven to improve outcomes for PeAF ablation beyond PVI. wide
area PV antral isolation is more routinely performed and often incorporates a significant part of the posterior
Recent studies suggest that contact force-sensing catheters are associated with more effective lesion
formation, with a recent meta-analysis of 11 studies demonstrating lower recurrence rates (odds ratio [OR]
0.62, 95% CI 0.45–0.86) with this technology
The only factor predictive of late AF recurrence in the studies in the current meta-analysis was early
recurrence. The first 3 months postablation have traditionally been considered a blanking period during which
recurrences were due to a transient atrial inflammatory response15 and not necessarily predictive of late
recurrence. However, another recent meta-analysis also observed that early recurrence within 30 days was
strongly predictive of late recurrence (OR 4.3) with similar predictive power as for LA diameter >5.0 cm (OR
5.1) and valvular AF (OR 5.2).
In STAR AF II, re-isolation of the veins improved AF-free survival from 59% to 72% at 18 months
In patients with PeAF and minimal structural heart disease, PVI alone yields a 1-year single-procedure
arrhythmia-free survival of 66.7% and is a legitimate strategy. These medium-term outcomes in lower-risk
patients are now comparable to results in the paroxysmal AF population, with very low complication rates.
PaAF -> PeAF cause of low voltage areas in LA
CB2 success rate for PaAF is 70%
Most important predictor of recurrent AF is Prior recurrences post ablation