Aggressive ablation vs. regular ablation for persistent atrial fibrillation: a multicentre real-world cohort study

Area of Science:

• Cardiology
• Electrophysiology
• Medical Devices

Background:

• Optimal ablation strategies for persistent atrial fibrillation (PerAF) require further clarification.
• Previous randomized controlled trials (RCTs) suggested favorable outcomes with aggressive ablation, but real-world data are limited.

Purpose of the Study:

• To evaluate the real-world effectiveness of aggressive versus regular catheter ablation strategies in patients with PerAF.
• To determine if achieving atrial fibrillation (AF) termination during ablation is a reliable endpoint.

Main Methods:

• A retrospective analysis of 4833 PerAF patients undergoing catheter ablation across 10 centers.
• Patients were categorized into regular ablation (PVI-only or PVI plus anatomical) and aggressive ablation (anatomical plus electrogram-guided) groups.
• Propensity score (PS) matching was used to compare outcomes, with a primary endpoint of 12-month AF/atrial tachycardia (AT) recurrence-free survival off anti-arrhythmic drugs.

Main Results:

• The aggressive ablation group demonstrated superior 12-month AF/AT-free survival (66.2% vs. 59.3%, P < 0.001) compared to the regular group.
• Procedural AF termination rates were significantly higher in the aggressive group (67.0% vs. 21.0%, P < 0.001), and achieving termination correlated with improved recurrence-free survival (72.3% vs. 55.2%, P < 0.001).
• Safety endpoints did not differ significantly; moderately aggressive ablation showed better outcomes than regular ablation, while extremely aggressive ablation showed declining trends.

Conclusions:

• Aggressive ablation strategies yield more favorable outcomes for PerAF patients compared to regular ablation.
• Moderately aggressive ablation appears to be associated with optimal clinical results.
• Atrial fibrillation termination during the procedure is a significant and reliable endpoint for successful ablation.