title: Ablation for longstanding permanent atrial fibrillation: results from a randomized study comparing three different strategies.
abstract: BACKGROUND
  This prospective multicenter randomized study aimed to compare the efficacy of 3 common ablation methods used for longstanding permanent atrial fibrillation (AF).
  
  
  METHODS
  A total of 144 patients with longstanding permanent AF (median duration 28 months) were randomly assigned to circumferential pulmonary vein ablation (CPVA, group 1, n = 47), to pulmonary vein antrum isolation (PVAI, group 2, n = 48) or to a hybrid strategy combining ablation of complex fractionated or rapid atrial electrograms (CFAE) in both atria followed by a pulmonary vein antrum isolation (CFAE + PVAI, group 3, n = 49).
  
  
  RESULTS
  Scarring in the left atrium and structural heart disease/hypertension were present in most patients (65%). After a mean follow-up of 16 months, 11% of patients in group 1, 40% of patients in group 2 and 61% of patients in group 3 were in sinus rhythm after one procedure and with no antiarrhythmic drugs (P < .001). Sinus rhythm maintenance would increase respectively to 28% (group 1), 83% (group 2), and 94% (group 3) after 2 procedures and with antiarrhythmic drugs (AADs, P < .001). The AF terminated during ablation, either by conversion to sinus rhythm or organization into an atrial tachyarrhythmia, in 13% of patients (group 1), 44% (group 2), and 74% (group 3) respectively. CFAE alone, performed as the first step of the ablation in group 3, organized AF in only 1 patient.
  
  
  CONCLUSIONS
  In this study, the hybrid AF ablation strategy including antrum isolation and CFAE ablation had the highest likelihood of maintaining sinus rhythm in patients with longstanding permanent AF. Electrical isolation of the PVs, although inadequate if performed alone, is relevant to achieve long-term sinus rhythm maintenance after ablation. Bi-atrial CFAE ablation had a minimal impact on AF termination during ablation.
authors.affiliation: Ambroise Pare Hospital, Neuilly sur Seine, France.
authors.forename: Claude S
authors.initials: CS
authors.lastname: Elayi
authors.forename: Atul
authors.initials: A
authors.lastname: Verma
authors.forename: Luigi
authors.initials: L
authors.lastname: Di Biase
authors.forename: Chi Keong
authors.initials: CK
authors.lastname: Ching
authors.forename: Dimpi
authors.initials: D
authors.lastname: Patel
authors.forename: Conor
authors.initials: C
authors.lastname: Barrett
authors.forename: David
authors.initials: D
authors.lastname: Martin
authors.forename: Bai
authors.initials: B
authors.lastname: Rong
authors.forename: Tamer S
authors.initials: TS
authors.lastname: Fahmy
authors.forename: Yaariv
authors.initials: Y
authors.lastname: Khaykin
authors.forename: Richard
authors.initials: R
authors.lastname: Hongo
authors.forename: Steven
authors.initials: S
authors.lastname: Hao
authors.forename: Gemma
authors.initials: G
authors.lastname: Pelargonio
authors.forename: Antonio
authors.initials: A
authors.lastname: Dello Russo
authors.forename: Michela
authors.initials: M
authors.lastname: Casella
authors.forename: Pietro
authors.initials: P
authors.lastname: Santarelli
authors.forename: Domenico
authors.initials: D
authors.lastname: Potenza
authors.forename: Raffaele
authors.initials: R
authors.lastname: Fanelli
authors.forename: Raimondo
authors.initials: R
authors.lastname: Massaro
authors.forename: Mauricio
authors.initials: M
authors.lastname: Arruda
authors.forename: Robert A
authors.initials: RA
authors.lastname: Schweikert
authors.forename: Andrea
authors.initials: A
authors.lastname: Natale
mesh_terms: D001281:Atrial Fibrillation / Q000503:physiopathology / Q000601:surgery*; D002908:Chronic Disease; D005260:Female; D005500:Follow-Up Studies; D006325:Heart Atria / Q000294:innervation / Q000503:physiopathology / Q000601:surgery*; D006329:Heart Conduction System / Q000503:physiopathology / Q000601:surgery*; D006339:Heart Rate; D006801:Humans; D017075:Laser Coagulation / Q000379:methods*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D011667:Pulmonary Veins / Q000294:innervation / Q000601:surgery*; D016896:Treatment Outcome