Persistent atrial fibrillation presenting in sinus rhythm: pulmonary vein isolation versus pulmonary vein isolation plus electrogram-guided ablation.
BACKGROUND
The classification of atrial fibrillation as paroxysmal or persistent (PsAF) is clinically useful, but does not accurately reflect the underlying pathophysiology and is therefore a suboptimal guide to selection of ablation strategy.


OBJECTIVE
To determine if additional substrate ablation is beneficial for a subset of patients with PsAF, in whom long periods of sinus rhythm (SR) can be maintained.


METHODS
We included patients presenting with PsAF in whom continuous periods of SR>3months were documented. All patients were in SR on the day of the procedure. Electrical pulmonary vein isolation (PVI) was performed in all patients. Additional electrogram (EGM)-guided ablation was left to the discretion of the operator. Patient characteristics and follow-up were analysed with respect to presence or absence of additional EGM-guided ablation.


RESULTS
Sixty-five patients (mean age 60.1±8.9years; 81.5% men) met the inclusion criteria. EGM-guided ablation was performed in 32 (49%) patients. Patients with and without EGM-guided ablation had similar baseline characteristics. Absence of EGM-guided ablation was one of the independent predictors for arrhythmia recurrences after the index procedure (hazard ratio 0.24; confidence interval 0.12-0.47). After a median follow-up of 18±10months, the number of procedures required was significantly higher in the 'PVI-only' group (2.24±0.75 vs. 1.84±0.81; P=0.04) to achieve a similar success rate (84% vs. 81%; P=0.833).


CONCLUSIONS
The addition of EGM-guided ablation requires fewer procedures to achieve similar clinical efficacy in mid-term follow-up compared with a PVI-only strategy in patients with PsAF presenting for ablation in SR.
Division of Cardiovascular Medicine, St. Thomas' Hospital, London, UK; The Rayne Institute, King's College London, London, UK; Fédération de Cardiologie, Hôpital Henri-Mondor, AP-HP et Inserm U 955, 51, avenue du Marechal-de-Lattre-de-Tassigny, 94000 Creteil, France.
Frederic A
FA
Sebag
Najia
N
Chaachoui
Nick W
NW
Linton
Sana
S
Amraoui
James
J
Harrison
Steven
S
Williams
Aldo C
AC
Rinaldi
Jaswinder
J
Gill
Michael
M
Cooklin
Senthil
S
Kirubakaran
Mark D
MD
O'Neill
Matthew
M
Wright
Nicolas
N
Lellouche
D000368:Aged; D001281:Atrial Fibrillation / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D017115:Catheter Ablation / Q000009:adverse effects / Q000379:methods*; D022062:Electrophysiologic Techniques, Cardiac; D005260:Female; D005602:France; D006801:Humans; D008131:London; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011667:Pulmonary Veins / Q000503:physiopathology / Q000601:surgery*; D012008:Recurrence; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome
AF; AFCL; AT; Ablation de fibrillation atriale; Ablation de substrat atrial; Atrial fibrillation; Atrial fibrillation ablation; Atrial fibrillation cycle length; Atrial tachycardia; DCCV; Direct current cardioversion; EGM; Electrogram; Electrogram-based ablation; Fibrillation atriale persistante; Isolation des veines pulmonaires; LA; Left atrium; PAF; PVI; Paroxysmal atrial fibrillation; Persistent atrial fibrillation; PsAF; Pulmonary vein isolation; SR; Sinus rhythm