Importance of Sinus Rhythm as Endpoint of Persistent Atrial Fibrillation Ablation

BACKGROUND:Pulmonary vein isolation (PVI) is effective for maintenance of sinus rhythm in 50% to 75% of patients with paroxysmal atrial fibrillation, and it is not uncommon for patients to require additional ablation after PVI. We prospectively evaluated the relative effectiveness of 2 post-PVI ablation strategies in paroxysmal atrial fibrillation. METHODS AND RESULTS:A total of 500 patients (mean age, 55.7±11.0 years; 74.6% male) were randomly assigned to undergo ablation by 2 different strategies after PVI: (1) elimination of non-PV triggers (group A, n=250) or (2) stepwise substrate modification including complex fractionated atrial electrogram or linear ablation until noninducibility of atrial tachyarrhythmia was achieved (group B, n=250). During a median follow-up of 26.0 months, 75 (32.2%) patients experienced at least 1 episode of recurrent atrial tachyarrhythmia after the single procedure in group A compared with 105 (43.8%) patients in group B (P value in log-rank test of Kaplan-Meier analysis: 0.012). Competing risk analysis showed that the cumulative incidence of atrial tachycardia was significantly higher in group B compared with group A (P=0.007). With the exception of total ablation time, there were no significant differences in fluoroscopic time or procedure-related complications between the 2 groups.CONCLUSIONS: Elimination of triggers as an end point of ablation in patients with paroxysmal atrial fibrillation decreased long-term recurrence of atrial tachyarrhythmia compared with a noninducibility approach achieved by additional empirical ablation. The post-PVI trigger test is thus a better end point of ablation for paroxysmal atrial fibrillation.

Section: Discussioncontrasting

confidence: 54%

Long-Term Clinical Comparison of Procedural End Points After Pulmonary Vein Isolation in Paroxysmal Atrial Fibrillation

Lee

Roh

Baek

et al. 2018

“…Compared with patients without AF termination, patients with AF termination had a shorter duration of continuous AF (12 [6][7][8][9][10][11][12][13][14][15][16][17][18][19] The rate of AF termination was similar in patients with and without amiodarone at the time of the procedure (75% versus 81%, P=0.58). Mean procedural and RF durations for patients in whom termination of AF was achieved versus not achieved were 264±74 minutes versus 263±64 minutes (P=0.91) and 89±28 minutes versus 99±27 minutes (P=0.09), respectively.…”

Section: Index Procedural Datamentioning

confidence: 87%

Five-Year Outcome of Catheter Ablation of Persistent Atrial Fibrillation Using Termination of Atrial Fibrillation as a Procedural Endpoint

Scherr

Khairy

Miyazaki

et al. 2015

280

254

Background-This study aimed to determine 5-year efficacy of catheter ablation for persistent atrial fibrillation (AF) using AF termination as a procedural end point. Methods and Results-One hundred fifty patients (57±10 years) underwent persistent AF ablation using a stepwise ablation approach (pulmonary vein isolation, electrogram-guided, and linear ablation) with the desired procedural end point being AF termination. Repeat ablation was performed for recurrent AF or atrial tachycardia. AF was terminated by ablation in 120 patients (80%). Arrhythmia-free survival rates after a single procedure were 35.3%±3.9%, 28.0%±3.7%, and 16.8%±3.2% at 1, 2, and 5 years, respectively. Arrhythmia-free survival rates after the last procedure (mean 2.1±1.0 procedures) were 89.7%±2.5%, 79.8%±3.4%, and 62.9%±4.5%, at 1, 2, and 5 years, respectively. During a median follow-up of 58 (interquartile range, 43-73) months after the last ablation procedure, 97 of 150 (64.7%) patients remained in sinus rhythm without antiarrhythmic drugs. Another 14 (9.3%) patients maintained sinus rhythm after reinitiation of antiarrhythmic drugs, and an additional 15 (10.0%) patients regressed to paroxysmal recurrences only. Failure to terminate AF during the index procedure (hazard ratio 3.831; 95% confidence interval, 2.070-7.143; P<0.001), left atrial diameter ≥50 mm (hazard ratio 2.083; 95% confidence interval, 1.078-4.016; P=0.03), continuous AF duration ≥18 months (hazard ratio 1.984; 95% confidence interval, 1.024-3.846; P<0.04), and structural heart disease (hazard ratio 1.874; 95% confidence interval, 1.037-3.388; P=0.04) predicted arrhythmia recurrence. Conclusions-In patients with persistent AF, an ablation strategy aiming at AF termination is associated with freedom from arrhythmia recurrence in the majority of patients over a 5-year follow-up period. Procedural AF nontermination and specific baseline factors predict long-term outcome after ablation. (Circ Arrhythm Electrophysiol. 2015;8:18-24.

“…3 Several studies have shown that termination is predictive for long-term maintenance of SR. [19][20][21][22]33 O'Neill et al reported lower recurrence rates in patients with AF termination during index procedure (5% versus 39%). Termination to SR being associated with the highest single procedure success rate compared with AT or AF at the end of the procedure (42% versus 13% and 25%) was shown by Ammar et al In contrast, Elayi et al noted no impact of termination on SR maintenance.…”

Section: Af Terminationmentioning

confidence: 99%

“…In contrast to ablation of PAF, in which the end point of electric isolation of the pulmonary veins (PVs) is recommended by the guidelines, the optimal end point of CA in the setting of persAF is still under debate. 3,[19][20][21][22] The stepwise ablation approach aiming at procedural AF termination was introduced by Haïssaguerre et al 10,23 in 2005. Long-term follow-up data on any ablation approach for persAF are limited.…”

mentioning

confidence: 99%

Five-Year Follow-Up After Catheter Ablation of Persistent Atrial Fibrillation Using the Stepwise Approach and Prognostic Factors for Success

Schreiber

Rostock

Fröhlich

et al. 2015

154

A total of 549 patients with persAF underwent CA using the stepwise approach at our institution in 2007 to 2009. Of these, 493 © 2015 American Heart Association, Inc. Original Article Circ Arrhythm ElectrophysiolBackground-In the meantime, catheter ablation is widely used for the treatment of persistent atrial fibrillation (AF). There is a paucity of data about long-term outcomes. This study evaluates (1) 5-year single and multiple procedure success and (2) prognostic factors for arrhythmia recurrences after catheter ablation of persistent AF using the stepwise approach aiming at AF termination. Methods and Results-A total of 549 patients with persistent AF underwent de novo catheter ablation using the stepwise approach (2007)(2008)(2009)