Effect of Catheter Ablation Using Pulmonary Vein Isolation With vs Without Posterior Left Atrial Wall Isolation on Atrial Arrhythmia Recurrence in Patients With Persistent Atrial Fibrillation

Abstract

ImportancePulmonary vein isolation (PVI) alone is less effective in patients with persistent atrial fibrillation (AF) compared with paroxysmal AF. The left atrial posterior wall may contribute to maintenance of persistent AF, and posterior wall isolation (PWI) is a common PVI adjunct. However, PWI has not been subjected to randomized comparison.ObjectiveTo compare PVI with PWI vs PVI alone in patients with persistent AF undergoing first-time catheter ablation.Design, Setting, and ParticipantsInvestigator initiated, multicenter, randomized clinical trial involving 11 centers in 3 countries (Australia, Canada, UK). Symptomatic patients with persistent AF were randomized 1:1 to either PVI with PWI or PVI alone. Patients were enrolled July 2018-March 2021, with 1-year follow-up completed March 2022.InterventionsThe PVI with PWI group (n = 170) underwent wide antral pulmonary vein isolation followed by posterior wall isolation involving linear ablation at the roof and floor to achieve electrical isolation. The PVI-alone group (n = 168) underwent wide antral pulmonary vein isolation alone.Main Outcomes and MeasuresPrimary end point was freedom from any documented atrial arrhythmia of more than 30 seconds without antiarrhythmic medication at 12 months, after a single ablation procedure. The 23 secondary outcomes included freedom from atrial arrhythmia with/without antiarrhythmic medication after multiple procedures, freedom from symptomatic AF with/without antiarrhythmic medication after multiple procedures, AF burden between study groups at 12 months, procedural outcomes, and complications.ResultsAmong 338 patients randomized (median age, 65.6 [IQR, 13.1] years; 76.9% men), 330 (97.6%) completed the study. After 12 months, 89 patients (52.4%) assigned to PVI with PWI were free from recurrent atrial arrhythmia without antiarrhythmic medication after a single procedure, compared with 90 (53.6%) assigned to PVI alone (between-group difference, –1.2%; hazard ratio [HR], 0.99 [95% CI, 0.73-1.36]; P = .98). Of the secondary end points, 9 showed no significant difference, including freedom from atrial arrhythmia with/without antiarrhythmic medication after multiple procedures (58.2% for PVI with PWI vs 60.1% for PVI alone; HR, 1.10 [95% CI, 0.79-1.55]; P = .57), freedom from symptomatic AF with/without antiarrhythmic medication after multiple procedures (68.2% vs 72%; HR, 1.20 [95% CI, 0.80-1.78]; P = .36) or AF burden (0% [IQR, 0%-2.3%] vs 0% [IQR, 0%-2.8%], P = .47). Mean procedural times (142 [SD, 69] vs 121 [SD, 57] minutes, P < .001) and ablation times (34 [SD, 21] vs 28 [SD, 12] minutes, P < .001) were significantly shorter for PVI alone. There were 6 complications for PVI with PWI and 4 for PVI alone.Conclusions and RelevanceIn patients undergoing first-time catheter ablation for persistent AF, the addition of PWI to PVI alone did not significantly improve freedom from atrial arrhythmia at 12 months compared with PVI alone. These findings do not support the empirical inclusion of PWI for ablation of persistent AF.Trial Registrationanzctr.org.au Identifier: ACTRN12616001436460

Extensive Posterior Wall Isolation on Top of Pulmonary Vein Isolation Guided by Ablation Index in Persistent Atrial Fibrillation Ablation

“…The introduction of AI as a marker of lesion quality to guide PWI in patients undergoing catheter ablation for Pe-AF has been recently advocated. However, the recent CAPLA randomized clinical trial raised doubts about empirical PWI in patients with Pe-AF [ 12 ]. Finally, most previous follow-up data are usually obtained via Holter monitoring, event recorders, or transtelephonic monitoring, not continuous rhythm monitoring.…”

“…Recently, the CAPLA randomized clinical trial did not show additional benefits when the empirical PWI was performed in patients with Pe-AF [ 12 ]. Nevertheless, there has been some criticism about this study.…”

Catheter Ablation for Persistent Atrial Fibrillation

“…The CAPLA (Catheter Ablation for Persistent Atrial Fibrillation: A Multicenter Randomized Trial of Pulmonary Vein Isolation vs PVI With Posterior Left Atrial Wall Isolation) trial studied the effect of ablation in 338 patients with symptomatic persistent AF of less than 3 years' duration for which 1 or more antiarrhythmic drugs had failed. 6 Participants were randomized to receive either PVI with PWI or PVI alone. Posterior wall lesions included a roof and floor ablation line that connected the ablated areas created by PVI to create a box, along with ablation within the resulting box, when necessary, to achieve electrical isolation of this region.…”

“…Regardless, several cohort studies and small randomized trials support the inclusion of posterior wall isolation (PWI) in addition to PVI in patients with persistent AF, although large-scale randomized trials have been lacking . It is in this context that the work of Kistler and colleagues in this issue of JAMA sheds further light, and more disappointment, on this important concern.…”

“…The CAPLA (Catheter Ablation for Persistent Atrial Fibrillation: A Multicenter Randomized Trial of Pulmonary Vein Isolation vs PVI With Posterior Left Atrial Wall Isolation) trial studied the effect of ablation in 338 patients with symptomatic persistent AF of less than 3 years’ duration for which 1 or more antiarrhythmic drugs had failed . Participants were randomized to receive either PVI with PWI or PVI alone.…”