A Simple Method Is Used to Identify PVI-Responsive Patients With Persistent Atrial Fibrillation: Electrical...

Area of Science:

• Electrophysiology
• Cardiology
• Medical Device Technology

Background:

• Pulmonary vein isolation (PVI) has limited efficacy in persistent atrial fibrillation (PersAF) compared to paroxysmal AF.
• Previous studies indicate additional ablation strategies beyond PVI offer minimal benefit in persistent AF.
• Identifying PVI-responsive patients with persistent AF is crucial for optimizing treatment.

Purpose of the Study:

• To assess a novel direct current cardioversion-electrophysiological study (DC-EPS) protocol for stratifying persistent AF patients.
• To evaluate if AF inducibility identified by DC-EPS can guide the extent of PVI procedures.
• To determine the efficacy of PVI alone versus PVI with adjunctive ablation based on DC-EPS results.

Main Methods:

• A prospective cohort study classified patients into Protocol-Negative (non-inducible post-cardioversion) and Protocol-Positive groups.
• Protocol-Negative patients received PVI alone; Protocol-Positive patients underwent PVI with adjunctive line ablation (Roof/MI/CTI).
• Procedure success was defined as freedom from atrial arrhythmias >30s without antiarrhythmic drugs at 12 months.

Main Results:

• At 12 months, 85.4% of Protocol-Negative patients and 60.7% of Protocol-Positive patients were arrhythmia-free.
• Arrhythmia-free survival was significantly higher in the Protocol-Negative group (HR=0.326, p=0.009), even after multivariable adjustment.
• Protocol-Negative patients had better cardiac architecture and less atrial fibrosis compared to Protocol-Positive patients.

Conclusions:

• DC-EPS-defined Protocol-Negativity identifies patients with a favorable response to PVI.
• PV antrum isolation may be sufficient as an initial procedure for these patients.
• Further multi-center randomized controlled trials are warranted to validate these findings.