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Coronary Sinus Isolation for High-Burden Atrial Fibrillation: A Randomized Clinical Trial
Jonathan P Ariyaratnam1, Melissa E Middeldorp2, Anthony G Brooks3
1Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia. Electronic address: https://twitter.com/JonathanAriya.
Insights
Coronary sinus isolation (CSI) did not improve atrial arrhythmia-free survival compared to pulmonary vein isolation (PVI) and roofline ablation alone for high-burden atrial fibrillation (AF). This adjunctive strategy showed no significant benefit in long-term outcomes.
Area of Science:
- Cardiology
- Electrophysiology
- Medical Devices
Background:
- The coronary sinus is implicated in initiating and sustaining atrial fibrillation (AF).
- Coronary sinus ablation can prolong AF cycle length and terminate AF, particularly in patients with persistent AF post-pulmonary vein isolation (PVI).
Purpose of the Study:
- To evaluate the efficacy of coronary sinus isolation (CSI) as an add-on ablation strategy for high-burden AF.
- To conduct a randomized controlled trial comparing CSI plus PVI/roofline versus PVI/roofline alone.
Main Methods:
- 100 patients with high-burden AF were randomized to PVI, roofline, and CSI, or PVI and roofline only.
- The primary outcome was 2-year drug-free atrial arrhythmia-free survival after a single procedure.
- Follow-up included clinical assessment and 7-day Holter monitoring.
Main Results:
- No significant difference in 2-year single-procedure drug-free survival between the CSI group (62.5%) and the non-CSI group (63.4%).
- No difference in multiple-procedure drug-assisted survival at 5 years.
- Complication rates were similar between the groups.
Conclusions:
- Adjunctive coronary sinus isolation (CSI) does not provide additional benefit over PVI and roofline ablation for de novo treatment of high-burden AF.
- CSI is not superior to standard PVI and roofline ablation in achieving long-term arrhythmia freedom.
Background:
The coronary sinus is an arrhythmogenic structure that can initiate and maintain atrial fibrillation (AF). Coronary sinus ablation has been shown to be effective in prolonging the AF cycle length and terminating AF in patients with both paroxysmal and persistent AF who have persistent AF after pulmonary vein isolation (PVI).
Objectives:
The objective of this study was to undertake a randomized controlled trial to investigate the efficacy of coronary sinus isolation (CSI) as an adjunctive ablation strategy for the treatment of high-burden AF.
Methods:
Consecutive patients presenting with symptomatic long episodes of paroxysmal AF (≥48 h but ≤7 days) or persistent AF (>7 days and ≤12 months) referred for first-time ablation were enrolled. Participants were randomized to either PVI, roofline ablation, and CSI (CSI group) or PVI and roofline ablation only (non-CSI group). Participants were assessed postprocedurally via clinical follow-up and 7-day Holter monitoring at regular intervals. The primary outcome was single-procedure drug-free atrial arrhythmia-free survival at 2 years.
Results:
A total of 100 participants were recruited to the study; 48 were randomized to the CSI group and 52 to the non-CSI group. Acutely successful CSI was achieved in 45 of the 48 patients in the CSI group. At 2 years follow up, 30 of 48 patients (62.5%) in the CSI group and 33 of 52 (63.4%) in the non-CSI group were free from arrhythmia recurrence. Single-procedure drug-free survival at 2 years was no different between groups (P = 0.91). Similarly, multiple procedure drug assisted survival at 5 years was not different between groups (P = 0.80). Complication rates were not significantly different between groups (P = 0.19).
Conclusions:
Adjunctive CSI as part of a de novo ablation strategy does not confer any additional benefit greater than PVI and roofline for the treatment of high-burden AF.
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