title: Sequential biatrial linear defragmentation approach for persistent atrial fibrillation.
abstract: BACKGROUND
  The strategy for catheter ablation of persistent atrial fibrillation (AF) and the procedural end point remain controversial.
  
  
  OBJECTIVE
  To evaluate the feasibility of a sequential defragmentation approach.
  
  
  METHODS
  One hundred thirty-five patients (aged 62.4 ± 9 years; 76 long-standing persistent AF) underwent first ablation procedure for persistent AF. With an end point of AF termination, the ablation procedure was performed sequentially in the following order: pulmonary vein antrum isolation, linear defragmentation of complex fractionated electrograms at left atrial (LA) roof, bottom, septum, inferior LA, base of LA appendage, anterior LA, right atrial septum, crista terminalis, and base of right atrial appendage. Ensuing atrial tachycardias (ATs) were mapped and ablated.
  
  
  RESULTS
  AF termination was achieved in 69 (51%) patients (59 in the left atrium and 10 in the right atrium). The total procedure and fluoroscopic times were 145.4 ± 36.1 and 35.1 ± 14.3 minutes, respectively. At median 19.0 months, 105 (78%) patients demonstrated recurrent atrial tachyarrhythmia necessitating repeat ablation procedure(s). With mean 1.7 ± 0.7 procedures per patient, 100 (74%) patients were free from atrial tachyarrhythmia at median 15.0-month follow-up. Among 73 mappable ATs, 49 were macroreentrant ATs. On multivariate Cox regression analysis, greater LA diameter (hazard ratio 1.10; 95% confidence interval 1.04-1.17; P = .0004) and non-AF termination (hazard ratio 1.50; 95% confidence interval 1.01-2.36; P = .036) were independent predictors of AF recurrence after single and multiple ablation procedures, respectively.
  
  
  CONCLUSIONS
  Pulmonary vein antrum isolation followed by biatrial substrate modification in a predetermined order of linear ablation of specific anatomical regions with predilection for complex fractionated atrial electrograms is a feasible alternative persistent AF ablation strategy.
authors.affiliation: Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan. mshinsuke@k3.dion.ne.jp
authors.forename: Shinsuke
authors.initials: S
authors.lastname: Miyazaki
authors.forename: Hiroshi
authors.initials: H
authors.lastname: Taniguchi
authors.forename: Yuki
authors.initials: Y
authors.lastname: Komatsu
authors.forename: Takashi
authors.initials: T
authors.lastname: Uchiyama
authors.forename: Shigeki
authors.initials: S
authors.lastname: Kusa
authors.forename: Hiroaki
authors.initials: H
authors.lastname: Nakamura
authors.forename: Hitoshi
authors.initials: H
authors.lastname: Hachiya
authors.forename: Mitsuaki
authors.initials: M
authors.lastname: Isobe
authors.forename: Kenzo
authors.initials: K
authors.lastname: Hirao
authors.forename: Yoshito
authors.initials: Y
authors.lastname: Iesaka
mesh_terms: D001281:Atrial Fibrillation / Q000503:physiopathology / Q000601:surgery*; D017115:Catheter Ablation / Q000379:methods*; D022062:Electrophysiologic Techniques, Cardiac / Q000379:methods*; D005240:Feasibility Studies; D005260:Female; D005500:Follow-Up Studies; D006325:Heart Atria / Q000294:innervation / Q000503:physiopathology / Q000601:surgery*; D006329:Heart Conduction System / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D016896:Treatment Outcome