Ablation for longstanding permanent atrial fibrillation: results from a randomized study comparing three different strategies.
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.
Elayi
Claude S
CS
Ambroise Pare Hospital, Neuilly sur Seine, France.
Verma
Atul
A
Di Biase
Luigi
L
Ching
Chi Keong
CK
Patel
Dimpi
D
Barrett
Conor
C
Martin
David
D
Rong
Bai
B
Fahmy
Tamer S
TS
Khaykin
Yaariv
Y
Hongo
Richard
R
Hao
Steven
S
Pelargonio
Gemma
G
Dello Russo
Antonio
A
Casella
Michela
M
Santarelli
Pietro
P
Potenza
Domenico
D
Fanelli
Raffaele
R
Massaro
Raimondo
R
Arruda
Mauricio
M
Schweikert
Robert A
RA
Natale
Andrea
A
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