Sequential biatrial linear defragmentation approach for persistent atrial fibrillation

The strategy for catheter ablation of persistent atrial fibrillation (AF) and the procedural end point remain controversial.

To evaluate the feasibility of a sequential defragmentation approach.

One hundred thirty-five patients (aged 62.4 ± 9 years; 76 long-standing persistent AF) underwent first ablation procedure for persistent AF. With an end point of AF termination, the ablation procedure was performed sequentially in the following order: pulmonary vein antrum isolation, linear defragmentation of complex fractionated electrograms at left atrial (LA) roof, bottom, septum, inferior LA, base of LA appendage, anterior LA, right atrial septum, crista terminalis, and base of right atrial appendage. Ensuing atrial tachycardias (ATs) were mapped and ablated.

AF termination was achieved in 69 (51%) patients (59 in the left atrium and 10 in the right atrium). The total procedure and fluoroscopic times were 145.4 ± 36.1 and 35.1 ± 14.3 minutes, respectively. At median 19.0 months, 105 (78%) patients demonstrated recurrent atrial tachyarrhythmia necessitating repeat ablation procedure(s). With mean 1.7 ± 0.7 procedures per patient, 100 (74%) patients were free from atrial tachyarrhythmia at median 15.0-month follow-up. Among 73 mappable ATs, 49 were macroreentrant ATs. On multivariate Cox regression analysis, greater LA diameter (hazard ratio 1.10; 95% confidence interval 1.04-1.17; P = .0004) and non-AF termination (hazard ratio 1.50; 95% confidence interval 1.01-2.36; P = .036) were independent predictors of AF recurrence after single and multiple ablation procedures, respectively.

Pulmonary vein antrum isolation followed by biatrial substrate modification in a predetermined order of linear ablation of specific anatomical regions with predilection for complex fractionated atrial electrograms is a feasible alternative persistent AF ablation strategy.