Pulmonary vein isolation alone in patients with persistent atrial fibrillation: an ablation strategy facilitated by antiarrhythmic drug induced reverse remodeling.
BACKGROUND
Pulmonary vein isolation (PVI) alone has been thought to be insufficient in patients with persistent atrial fibrillation (PersAF). We hypothesized that preablation treatment of PersAF with a potent antiarrhythmic drug (AAD) would facilitate reverse atrial remodeling and result in high procedural efficacy after PVI alone.


RESULTS
Seventy-one consecutive patients (59.4 ± 9.8 years) with PersAF and prior AAD failure were treated with oral dofetilide (768 ± 291 mcg/day) for a median of 85 days pre-PVI. P-wave duration (Pdur) on ECG was used to assess reverse atrial remodeling. Thirty-five patients with paroxysmal (P) AF not treated with an AAD served as controls. All patients underwent PVI alone; dofetilide was discontinued 1-3 mos postablation. In the PersAF patients, the Pdur decreased from 136.3 ± 21.7 ms (assessed postcardioversion on dofetilide) to 118.6 ± 20.4 ms (assessed immediately prior to PVI) (P < 0.001). In contrast, no change in Pdur (122.6 ± 11.5 ms vs. 121.3 ± 13.7 ms, P = NS) was observed in PAF patients. The 6 and 12 mos AAD-free response to ablation was 76% and 70%, respectively, in PersAF patients, similar to the 80% and 75%, response in PAF patients (P = NS). A decline in Pdur in response to dofetilide was the only predictor of long-term clinical response to PVI in patients with PersAF.


CONCLUSIONS
Pre-treatment with AAD resulted in a decrease in Pdur suggesting reverse atrial electrical remodeling in PersAF patients. This may explain the excellent clinical outcomes using PVI alone, and may suggest an alternative ablation strategy for PersAF.
Khan
Aslam
A
Division of Cardiology, Al-Sabah Arrhythmia Institute, St. Luke's and Roosevelt Hospitals, Columbia University College of Physicians & Surgeons, New York, NY, USA.
Mittal
Suneet
S
Kamath
Ganesh S
GS
Garikipati
Naga Vamsi
NV
Marrero
Daniel
D
Steinberg
Jonathan S
JS
D000889:Anti-Arrhythmia Agents / Q000008:administration & dosage; D001281:Atrial Fibrillation / Q000175:diagnosis / Q000628:therapy*; D017115:Catheter Ablation / Q000379:methods*; D002908:Chronic Disease; D003131:Combined Modality Therapy; D005260:Female; D006329:Heart Conduction System / Q000187:drug effects / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010627:Phenethylamines / Q000008:administration & dosage*; D011667:Pulmonary Veins / Q000601:surgery*; D013449:Sulfonamides / Q000008:administration & dosage*; D016896:Treatment Outcome
D000889:Anti-Arrhythmia Agents; D010627:Phenethylamines; D013449:Sulfonamides; C063533:dofetilide