title: Substrate modification combined with pulmonary vein isolation improves outcome of catheter ablation in patients with persistent atrial fibrillation: a prospective randomized comparison.
abstract: OBJECTIVE
  To investigate the effectiveness of additional substrate modification (SM) by left atrial (LA) linear lesions as compared with pulmonary vein isolation (PVI) alone in patients with persistent atrial fibrillation (AF) in a prospective randomized study. Percutaneous PVI has evolved as an accepted treatment for paroxysmal AF but seemed to be less effective in patients with persistent AF. The benefit of PVI alone and additional linear lesions has not been validated in a randomized study so far.
  
  
  RESULTS
  Sixty-two patients with persistent AF (median duration 7, range 1-18 months) were randomly assigned to either PVI alone (n = 30) or additional SM (n =32) consisting of a roof line connecting both left superior and right superior PV and LA isthmus ablation between left inferior PV and mitral annulus. Procedures including SM were performed using a three-dimensional mapping system (EnSite NavX, St Jude Medical, St Paul, MN, USA). Anti-arrhythmic drugs were discontinued within 8 weeks after ablation in both groups. Follow-up included daily trans-telephonic ECG transmitted irrespective of the patient's symptoms. PVI was successful in 98% of all targeted veins in both groups. Additional SM did not increase fluoroscopy time (72.1+/-18.7 vs. 72.9+/-17.3 min, P=0.92) because of the use of three-dimensional navigation in the PVI+SM group. AF recurrences within the first 4 weeks following ablation were more common after PVI alone (77%) than additional SM (44%, P=0.002). After a follow-up time of 487 (429-570) days, only 20% of patients undergoing stand alone PVI remained in sinus rhythm when compared with 69% following PVI combined with SM (P=0.0001). Two patients assigned to PVI+SM experienced procedure-related complications (cardiac tamponade and minor stroke) which resolved without sequelae.
  
  
  CONCLUSIONS
  PVI alone is insufficient in the treatment of persistent AF. However, additional left linear lesions increase the success rate significantly. Early AF-relapses are associated with a negative outcome after PVI alone but not following additional SM.
authors.affiliation: Department of Cardiology, University Hospital Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany. willems@uke.uni-hamburg.de
authors.forename: Stephan
authors.initials: S
authors.lastname: Willems
authors.forename: Hanno
authors.initials: H
authors.lastname: Klemm
authors.forename: Thomas
authors.initials: T
authors.lastname: Rostock
authors.forename: Benedikt
authors.initials: B
authors.lastname: Brandstrup
authors.forename: Rodolfo
authors.initials: R
authors.lastname: Ventura
authors.forename: Daniel
authors.initials: D
authors.lastname: Steven
authors.forename: Tim
authors.initials: T
authors.lastname: Risius
authors.forename: Boris
authors.initials: B
authors.lastname: Lutomsky
authors.forename: Thomas
authors.initials: T
authors.lastname: Meinertz
mesh_terms: D001281:Atrial Fibrillation / Q000601:surgery*; D001783:Blood Flow Velocity; D017115:Catheter Ablation / Q000379:methods*; D017548:Echocardiography, Transesophageal; D004562:Electrocardiography / Q000379:methods; D022062:Electrophysiologic Techniques, Cardiac; D006801:Humans; D008875:Middle Aged; D011446:Prospective Studies; D011667:Pulmonary Veins; D012008:Recurrence; D016896:Treatment Outcome