Atrial fibrillation termination as a procedural endpoint during ablation in long-standing persistent atrial fibrillation.
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.
Elayi
Claude S
CS
University of Lexington, Lexington, Kentucky, USA.
Di Biase
Luigi
L
Barrett
Conor
C
Ching
Chi Keong
CK
al Aly
Moataz
M
Lucciola
Maria
M
Bai
Rong
R
Horton
Rodney
R
Fahmy
Tamer S
TS
Verma
Atul
A
Khaykin
Yaariv
Y
Shah
Jignesh
J
Morales
Gustavo
G
Hongo
Richard
R
Hao
Steven
S
Beheiry
Salwa
S
Arruda
Mauricio
M
Schweikert
Robert A
RA
Cummings
Jennifer
J
Burkhardt
J David
JD
Wang
Paul
P
Al-Ahmad
Amin
A
Cauchemez
Bruno
B
Gaita
Fiorenzo
F
Natale
Andrea
A
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