Approaches to Catheter Ablation for Persistent Atrial Fibrillation

TLDR

Catheter ablation is less successful for persistent atrial fibrillation than for paroxysmal atrial fibrillation, and guidelines recommend adding substrate modification to pulmonary‑vein isolation in persistent cases. In a randomized trial of 589 patients, three ablation strategies were compared over 18 months: pulmonary‑vein isolation alone, isolation plus complex fractionated electrogram ablation, and isolation plus linear roof and mitral isthmus ablation, with procedure time shortest for isolation alone. After 18 months, freedom from atrial fibrillation was 59 % with isolation alone versus 49 % and 46 % with the two adjunctive strategies, with no significant differences among groups and no reduction in recurrence from added substrate modification; complications were rare. Funded by St.

Abstract

Catheter ablation is less successful for persistent atrial fibrillation than for paroxysmal atrial fibrillation. Guidelines suggest that adjuvant substrate modification in addition to pulmonary-vein isolation is required in persistent atrial fibrillation.We randomly assigned 589 patients with persistent atrial fibrillation in a 1:4:4 ratio to ablation with pulmonary-vein isolation alone (67 patients), pulmonary-vein isolation plus ablation of electrograms showing complex fractionated activity (263 patients), or pulmonary-vein isolation plus additional linear ablation across the left atrial roof and mitral valve isthmus (259 patients). The duration of follow-up was 18 months. The primary end point was freedom from any documented recurrence of atrial fibrillation lasting longer than 30 seconds after a single ablation procedure.Procedure time was significantly shorter for pulmonary-vein isolation alone than for the other two procedures (P<0.001). After 18 months, 59% of patients assigned to pulmonary-vein isolation alone were free from recurrent atrial fibrillation, as compared with 49% of patients assigned to pulmonary-vein isolation plus complex electrogram ablation and 46% of patients assigned to pulmonary-vein isolation plus linear ablation (P=0.15). There were also no significant differences among the three groups for the secondary end points, including freedom from atrial fibrillation after two ablation procedures and freedom from any atrial arrhythmia. Complications included tamponade (three patients), stroke or transient ischemic attack (three patients), and atrioesophageal fistula (one patient).Among patients with persistent atrial fibrillation, we found no reduction in the rate of recurrent atrial fibrillation when either linear ablation or ablation of complex fractionated electrograms was performed in addition to pulmonary-vein isolation. (Funded by St. Jude Medical; ClinicalTrials.gov number, NCT01203748.).