Radiofrequency catheter ablation of persistent atrial fibrillation by pulmonary vein isolation with or without left atrial posterior wall isolation: long-term outcomes of the CAPLA trial

Abstract

Background and Aims Posterior wall isolation (PWI) is commonly incorporated into catheter ablation (CA) strategies for persistent atrial fibrillation (AF) in an attempt to improve outcomes. In the CAPLA randomized study, adjunctive PWI did not improve freedom from atrial arrhythmia at 12 months compared with pulmonary vein isolation (PVI) alone. Whether additional PWI reduces arrhythmia recurrence over the longer term remains unknown. Methods In this multi-centre, international, randomized study patients with persistent AF undergoing index CA using radiofrequency were randomized to PVI + PWI vs. PVI alone. Patients underwent regular follow-up including rhythm monitoring for a minimum of 3 years after CA. Atrial fibrillation burden at 3 years after ablation was evaluated with either 28-day continuous ambulatory electrocardiogram (ECG) monitoring, twice daily single-lead ECG or from cardiac implanted device. Evaluated endpoints included freedom from any documented atrial arrhythmia recurrence after a single procedure, AF burden, need for redo CA, rhythm at last clinical follow-up, healthcare utilization metrics, and AF-related quality of life. Results Three hundred thirty-three of 338 (98.5%) patients (mean age 64.3 ± 9.4 years, 23% female) completed 3-year follow-up, with 169 patients randomized to PVI + PWI and 164 patients to PVI alone. At a median of 3.62 years after index ablation, freedom from recurrent atrial arrhythmia occurred in 59 patients (35.5%) randomized to PVI + PWI vs. 68 patients (42.1%) randomized to PVI alone (hazard ratio 1.15, 95% confidence interval 0.88–1.51, P = .55). Median time to recurrent atrial arrhythmia was 0.53 years (interquartile range 0.34–1.01 years). Redo ablation was performed in 54 patients (32.0%) in the PVI + PWI group vs. 49 patients (29.9%, P = .68) in the PVI alone group. Pulmonary vein reconnection was present in 54.5% (mean number of reconnected PVs 2.2 ± .9) and posterior wall reconnection in 75%. Median AF burden at 3 years was 0% in both groups (interquartile range 0%–0.85% PVI + PWI vs. 0%–1.43% PVI alone, P = .49). Sinus rhythm at final clinical follow-up was present in 85.1% with PVI + PWI vs. 87.1% with PVI alone (P = .60). Mean AF Effect On Quality-Of-Life (AFEQT) score at 3 years after ablation was 88.0 ± 14.8 with PVI + PWI vs. 88.9 ± 15.4 with PVI alone (P = .63). Conclusions In patients with persistent AF, the addition of PWI to PVI alone at index radiofrequency CA did not significantly improve freedom from atrial arrhythmia recurrence at long-term follow-up. Median AF burden remains low and AF quality of life high at 3 years with either ablation strategy.