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PVI-only is not enough for all patients with persistent AF: A FLOW-AF subgroup analysis
Atul Verma1, Steven Castellano2, Melissa H Kong2
1McGill University Health Centre, Montréal, Québec, Canada.
Heart Rhythm
|October 24, 2024
Summary
Pulmonary vein isolation (PVI)-only ablation is less successful for persistent atrial fibrillation (PeAF) patients with electrographic flow (EGF)-identified sources. EGF mapping helps identify patients who may require additional ablation beyond PVI for better outcomes.
Area of Science:
- Electrophysiology
- Cardiac Ablation
- Atrial Fibrillation Pathophysiology
Background:
- A trend towards pulmonary vein isolation (PVI)-only strategies for persistent atrial fibrillation (PeAF) exists post-STAR-AF II.
- Electrographic flow (EGF) mapping identifies atrial fibrillation (AF) sources and assesses wavefront propagation consistency (EGFC), revealing functional AF mechanisms.
Purpose of the Study:
- To evaluate the efficacy of a PVI-only ablation strategy in patients undergoing redo ablation for persistent or longstanding persistent atrial fibrillation.
- To determine if electrographic flow (EGF) identified sources impact the success of PVI-only ablation in this patient population.
Main Methods:
- The FLOW-AF trial prospectively enrolled patients with nonparoxysmal AF undergoing redo ablation.
- Electrographic flow (EGF) recordings were obtained pre- and post-PVI.
- Patients with EGF-identified sources were randomized to EGF-guided ablation versus PVI-only; those without sources mostly received PVI only.
Main Results:
- Patients without EGF-identified sources who received PVI-only ablation had a 70% freedom from recurrent AF (FFAF) rate at 1 year.
- Patients with EGF-identified sources randomized to PVI-only had a significantly lower FFAF rate of 35% (P = .018).
- Higher electrographic flow consistency (EGFC) correlated with better outcomes (67% FFAF) compared to low EGFC (45% FFAF, P = .011).
Conclusions:
- PVI-only ablation success rates are higher in patients without EGF-identified sources compared to those with sources randomized to PVI-only.
- The presence of EGF-identified sources is clinically significant in heterogeneous PeAF populations.
- PVI-only ablation may not be sufficient for all patients with persistent atrial fibrillation.
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