Anatomy Versus Physiology-Guided Ablation for Persistent Atrial Fibrillation

Area of Science:

• Cardiology
• Electrophysiology
• Medical Device Technology

Background:

• Pulmonary vein isolation (PVI) is standard for atrial fibrillation (AF) ablation, but recurrence rates, especially in persistent AF, necessitate complementary strategies.
• Techniques like linear ablation and complex fractionated atrial electrogram (CFAE) ablation are explored to improve PVI success rates.
• The optimal adjunctive strategy to PVI for persistent AF remains undetermined.

Purpose of the Study:

• To compare the efficacy of PVI combined with linear ablation versus PVI combined with CFAE ablation in patients with persistent AF.
• To evaluate the long-term success rates of these two complementary ablation strategies.

Main Methods:

• A prospective randomized trial involving 92 patients with persistent AF.
• Patients were assigned to either PVI + linear ablation (n=47) or PVI + CFAE ablation (n=45).
• The primary endpoint was freedom from AF recurrence after a single procedure, with a five-year follow-up.

Main Results:

• At 12 months, AF recurrence rates were 23% for linear ablation and 21% for CFAE ablation.
• At a mean follow-up of 59 months, freedom from AF was 48.3% in the linear group and 44.6% in the CFAE group (p=0.403).
• No significant differences in AF recurrence or predictors of success were observed between the groups; however, PVI + linear ablation involved longer procedure times and higher radiation exposure.

Conclusions:

• In patients with persistent AF, adding either linear ablation or CFAE ablation to PVI does not significantly improve the maintenance of sinus rhythm in the short or long term.
• Both strategies demonstrate comparable efficacy for persistent AF ablation when used as an adjunct to PVI.
• The choice between these adjunctive techniques may consider factors beyond efficacy, such as procedure time and radiation exposure.