C atheter ablation has become a routine treatment option for patients experiencing symptomatic paroxysmal atrial fibrillation (AF). Long-term clinical success rates of ≤80% after 5 years have been reported for the treatment of paroxysmal AF by initial stand-alone pulmonary vein isolation (PVI) as the accepted cornerstone of all AF ablation strategies; however, to achieve permanent PVI, multiple procedures are often required. 1,2 In contrast, the results for ablation of persistent AF are less convincing. 3 The optimal strategy for persistent AF is not known, and previous studies investigating more extensive ablation strategies in addition to PVI demonstrated heterogeneous results. [4][5][6][7][8][9][10][11][12] The recently published STAR AF 2 trial (Substrate and Trigger Ablation for Reduction of Atrial Fibrillation Trial) compared initial stand-alone PVI to PVI with additional ablation of complex fractionated atrial electrograms (CFAEs) or additional linear ablation and could not demonstrate a superior outcome for the additional ablation strategies. 13 The prospective and randomized Alster-Lost-AF © 2017 American Heart Association, Inc. Original ArticleBackground-Pulmonary vein isolation (PVI) for persistent atrial fibrillation is associated with limited success rates and often requires multiple procedures to maintain stable sinus rhythm. In the prospective and randomized Alster-Lost-AF trial (Ablation at St. Georg Hospital for Long-Standing Persistent Atrial Fibrillation), we sought to assess, in patients with symptomatic persistent or long-standing persistent atrial fibrillation, the outcomes of initial ablative strategies comprising either stand-alone PVI (PVI-only approach) or a stepwise approach of PVI followed by complex fractionated atrial electrogram ablation and linear ablation (Substrate-modification approach). Methods and Results-Patients were randomized 1:1 to stand-alone PVI or PVI plus substrate modification. The primary study end point was freedom from recurrence of any atrial tachyarrhythmia, outside a 90-day blanking period, at 12 months. A total of 124 patients were enrolled, with 118 patients included in the analysis (61 in the PVI-only group, 57 in the Substrate-modification group). Atrial tachyarrhythmias recurred in 28 PVI-only group patients and 24 Substratemodification group patients, for 1-year freedom from tachyarrhythmia recurrence after a single ablation procedure of 54% (95% confidence interval, 43%-68%) in the PVI-only and 57% (95% confidence interval, 46%-72%) in the Substratemodification group (P=0.86). Twenty-four patients in the PVI-only group (39%) and 18 in the Substrate-modification group (32%) were without arrhythmia recurrence and off antiarrhythmic drug therapy at the end of the 12-month follow-up. Conclusions-In

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Patients with an LCPV undergoing CB2-based PVI demonstrate a high acute success rate. Comparable results with regard to clinical success and durability of PVI were shown when comparing patients of the LCPV group and the control group.

BackgroundSecond-generation cryoballoon based pulmonary vein isolation has demonstrated encouraging acute and mid-term clinical outcome. Customarily, a bonus-freeze is applied after successful pulmonary vein isolation.ObjectiveTo compare the long-term clinical outcome and safety profile of a bonus-freeze and a no bonus-freeze protocol.MethodsA total of 120 consecutive patients with paroxysmal [95/120 (79 %)] or persistent atrial fibrillation [25/120 (21 %)] underwent CB2-based PVI. Freeze-cycle duration was 240 s. In the first 60 patients a bonus-freeze was applied after successful PVI (group 1), while in the following 60 patients the bonus-freeze was omitted (group 2).ResultsProcedure and fluoroscopy times were significantly shorter in group 2 [113.8 ± 32 vs 138.2 ± 29 min (p = 0.03) and 19.2 ± 6 vs 24.3 ± 8 min (p = 0.02)]. No differences in procedural complications were found. During a mean follow-up of 849 ± 74 (group 1) and 848 ± 101 days (group 2, p = 0.13) 69 % of patients (group 1) and 67 % of patients (group 2) remained in stable sinus rhythm without any differences between the groups (p = 0.69).ConclusionsFreedom from atrial fibrillation after second-generation cryoballoon based pulmonary vein isolation and a follow-up of >2 years is comparable when applying a bonus- and a no bonus-freeze protocol, while procedure and fluoroscopy times are significantly shorter when omitting the bonus-freeze. No differences in periprocedural complications were identified.

Integrating an individual TTI protocol to CB-based PVI results in shorter freeze-cycle applications in a substantial portion of targeted PVs and an arrhythmia-free survival comparable to conventional ablation protocols. The complication rate is low.