Pulmonary Vein Antral Isolation and Nonpulmonary Vein Trigger Ablation Are Sufficient to Achieve Favorable Long-Term Outcomes Including Transformation to Paroxysmal Arrhythmias in Patients With Persistent and Long-Standing Persistent Atrial Fibrillation

Abstract

A lthough pulmonary vein isolation (PVI) is well accepted to be the cornerstone of ablation for paroxysmal atrial fibrillation (AF), there remains lack of consensus on the optimal ablation strategy in patients with persistent and longstanding persistent AF. [1][2][3] Although an ablation strategy limited primarily to PVI, with or without targeting of documented nonpulmonary vein (PV) triggers, results in lower long-term AF-free survival rates in patients with persistent and longstanding persistent AF than paroxysmal AF, outcomes are not improved with more extensive substrate modification strategies.2,3 It has been shown that ≈50% of patients with persistent and long-standing persistent AF who undergo extensive substrate modification experience persistent organized atrial tachyarrhythmias (OAT) after ablation. 4,5 In contrast, patients with persistent and long-standing persistent AF treated with a more targeted ablation strategy (PVI with or without documented non-PV trigger ablation) are more likely to experience arrhythmia recurrences in the form of AF instead of OATs. However, when the arrhythmia recurrence in these patients is paroxysmal in nature, this likely suggests a favorable modification of the underlying AF substrate, which becomes less capable of sustaining AF.The objective of this study, therefore, was to determine the nature of initial arrhythmia recurrence in patients with © 2016 American Heart Association, Inc. Original ArticleBackground-Transformation from persistent to paroxysmal atrial fibrillation (AF) after ablation suggests modification of the underlying substrate. We examined the nature of initial arrhythmia recurrence in patients with nonparoxysmal AF undergoing antral pulmonary vein isolation and nonpulmonary vein trigger ablation and correlated recurrence type with long-term ablation efficacy after the last procedure. Methods and Results-Three hundred and seventeen consecutive patients with persistent (n=200) and long-standing persistent (n=117) AF undergoing first ablation were included. AF recurrence was defined as early (≤6 weeks) or late (>6 weeks after ablation) and paroxysmal (either spontaneous conversion or treated with cardioversion ≤7 days) or persistent (lasting >7 days). During median follow-up of 29.8 (interquartile range: 14.8-49.9) months, 221 patients had ≥1 recurrence. Initial recurrence was paroxysmal in 169 patients (76%) and persistent in 52 patients (24%). Patients experiencing paroxysmal (versus persistent) initial recurrence were more likely to achieve long-term freedom off antiarrhythmic drugs (hazard ratio, 2.2; 95% confidence interval, 1.5-3.2; P<0.0001), freedom on/off antiarrhythmic drugs (hazard ratio, 2.5; 95% confidence interval, 1.6-3.8; P<0.0001), and arrhythmia control (hazard ratio, 5.2; 95% confidence interval, 2.9-9.2; P<0.0001) after last ablation. Conclusions-In patients with persistent and long-standing persistent AF, limited ablation targeting pulmonary veins and documented nonpulmonary vein triggers improves the maintenance of sinus rhythm and re...

Impact of electrophysiological and pharmacological noninducibility following pulmonary vein isolation in patients with paroxysmal and persistent atrial fibrillation

“…Consistent with our findings, the recent meta‐analysis of the PVI‐only strategy in persistent AF patients showed a single‐procedure arrhythmia‐free survival rate of 66.7% . A limited ablation strategy of PVI and ablation of only documented non‐PV triggers was also found to provide transformation from persistent to paroxysmal AF, and good long‐term AF control with a low frequency of AT in the majority of patients …”

“…Second, residual or recurrent triggers after the ablation proce- Consistent with our findings, the recent meta-analysis of the PVI-only strategy in persistent AF patients showed a single-procedure arrhythmia-free survival rate of 66.7%. 32 A limited ablation strategy of PVI and ablation of only documented non-PV triggers was also found to provide transformation from persistent to paroxysmal AF, 33 and good long-term AF control with a low frequency of AT in the majority of patients. 34 Our data also indicated that patients with more enlarged LA diameter and with diabetes mellitus were more likely to have inducible atrial tachyarrhythmias in persistent AF.…”

Mechanisms and clinical significance of early recurrences of atrial arrhythmias after catheter ablation for atrial fibrillation

“…We have recently shown that in patients with nonparoxysmal AF treated with a limited ablation strategy of antral PVI and targeting of non-PV triggers, patients who recur as paroxysmal (rather than persistent) AF type are more likely to experience long-term ablation success[49]. We believe that patients with persistent or longstanding persistent AF who experience paroxysmal-type ERAA after ablation may represent a subgroup of patients in whom early reablation (even during the blanking period) can improve long-term ablation success.…”

Strategy and Outcome of Catheter Ablation for Persistent Atrial Fibrillation ― Impact of Progress in the Mapping and Ablation Technologies ―

“…46, 47 On the other hand, limited ablation targeting PVs and documented non-PV triggers improved the maintenance of sinus rhythm in persistent and longstanding persistent AF. 48 These results suggest that localization and ablation of documented non-PV triggers is important to improve the outcome of ablation for persistent AF.…”