title: Atrial fibrillation termination as a procedural endpoint during ablation in long-standing persistent atrial fibrillation.
abstract: BACKGROUND
  Ablation of long-standing persistent atrial fibrillation (AF) remains challenging, with a lower success rate than paroxysmal AF. A reliable ablation endpoint has not been demonstrated yet, although AF termination during ablation may be associated with higher long-term maintenance of sinus rhythm (SR).
  
  
  OBJECTIVE
  The purpose of this study was to determine whether the method of AF termination during ablation predicts mode of recurrence or long-term outcome.
  
  
  METHODS
  Three hundred six patients with long-standing persistent AF, free of antiarrhythmic drugs (AADs), undergoing a first radiofrequency ablation (pulmonary vein [PV] antrum isolation and complex fractionated atrial electrograms) were prospectively included. Organized atrial tachyarrhythmias (AT) that occurred during AF ablation were targeted. AF termination mode during ablation was studied in relation to other variables (characteristics of arrhythmia recurrence, redo procedures, the use of adenosine/isoproterenol for redo, and comparison of focal versus macroreentrant ATs). Long-term maintenance of SR was assessed during the follow-up.
  
  
  RESULTS
  During AF ablation, six of 306 patients converted directly to SR, 172 patients organized into AT (with 38 of them converting in SR with further ablation), and 128 did not organize or terminate and were cardioverted. Two hundred eleven of 306 patients (69%) maintained in long-term SR without AADs after a mean follow-up of 25 +/- 6.9 months, with no statistical difference between the various AF termination modes during ablation. Presence or absence of organization during ablation clearly predicted the predominant mode of recurrence, respectively, AT or AF (P = .022). Among the 74 redo ablation patients, 24 patients (32%) had extra PV triggers revealed by adenosine/isoproterenol. Termination of focal ATs was correlated with higher long-term success rate (24/29, 83%) than termination of macroreentrant ATs (20/35, 57%; P = .026).
  
  
  CONCLUSIONS
  AF termination during ablation (conversion to AT or SR) could predict the mode of arrhythmia recurrence (AT vs. AF) but did not impact the long-term SR maintenance after one or two procedures. AT termination with further ablation did not correlate with better long-term outcome, except with focal ATs, for which termination seems critical.
authors.affiliation: University of Lexington, Lexington, Kentucky, USA.
authors.forename: Claude S
authors.initials: CS
authors.lastname: Elayi
authors.forename: Luigi
authors.initials: L
authors.lastname: Di Biase
authors.forename: Conor
authors.initials: C
authors.lastname: Barrett
authors.forename: Chi Keong
authors.initials: CK
authors.lastname: Ching
authors.forename: Moataz
authors.initials: M
authors.lastname: al Aly
authors.forename: Maria
authors.initials: M
authors.lastname: Lucciola
authors.forename: Rong
authors.initials: R
authors.lastname: Bai
authors.forename: Rodney
authors.initials: R
authors.lastname: Horton
authors.forename: Tamer S
authors.initials: TS
authors.lastname: Fahmy
authors.forename: Atul
authors.initials: A
authors.lastname: Verma
authors.forename: Yaariv
authors.initials: Y
authors.lastname: Khaykin
authors.forename: Jignesh
authors.initials: J
authors.lastname: Shah
authors.forename: Gustavo
authors.initials: G
authors.lastname: Morales
authors.forename: Richard
authors.initials: R
authors.lastname: Hongo
authors.forename: Steven
authors.initials: S
authors.lastname: Hao
authors.forename: Salwa
authors.initials: S
authors.lastname: Beheiry
authors.forename: Mauricio
authors.initials: M
authors.lastname: Arruda
authors.forename: Robert A
authors.initials: RA
authors.lastname: Schweikert
authors.forename: Jennifer
authors.initials: J
authors.lastname: Cummings
authors.forename: J David
authors.initials: JD
authors.lastname: Burkhardt
authors.forename: Paul
authors.initials: P
authors.lastname: Wang
authors.forename: Amin
authors.initials: A
authors.lastname: Al-Ahmad
authors.forename: Bruno
authors.initials: B
authors.lastname: Cauchemez
authors.forename: Fiorenzo
authors.initials: F
authors.lastname: Gaita
authors.forename: Andrea
authors.initials: A
authors.lastname: Natale
mesh_terms: D001281:Atrial Fibrillation / Q000503:physiopathology / Q000601:surgery*; D017115:Catheter Ablation / Q000379:methods*; D022062:Electrophysiologic Techniques, Cardiac; D005260:Female; D005500:Follow-Up Studies; D006329:Heart Conduction System / Q000503:physiopathology*; D006339:Heart Rate / Q000502:physiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative / Q000379:methods*; D011446:Prospective Studies; D013997:Time Factors; D016896:Treatment Outcome