Proven isolation of the pulmonary vein antrum with or without left atrial posterior wall isolation in patients with persistent atrial fibrillation.
BACKGROUND
It is unclear whether isolation of the left atrial posterior wall (LAPW) offers additional benefits over pulmonary vein antrum isolation (PVAI) alone in patients with persistent atrial fibrillation (AF).


OBJECTIVE
We sought to determine the impact of PVAI and LAPW isolation (PVAI+LAPW) versus PVAI alone on the outcome of ablation of persistent AF.


METHODS
During the first procedure, PVAI was performed in 20 patients (group 1), whereas in 32 patients (group 2), PVAI was extended to the left atrial (LA) septum and coronary sinus (CS), and isolation of the LAPW was targeted (ePVAI+LAPW). Isolation of the superior vena cava was achieved in both groups. All patients, regardless of arrhythmia recurrence, underwent a second procedure 3 months after the first procedure. In patients with reconnection of pulmonary veins or LAPW, reisolation was performed, and a third procedure was performed 3 months later to verify isolation. Patients entered follow-up only after PVAI (group 1) or PVAI+LAPW (group 2) isolation was proven.


RESULTS
At the 1-, 2-, and 3-year follow-up examinations, the rates of freedom from atrial tachyarrhythmia without use of an antiarrhythmic drug were 20%, 15%, and 10% in group 1 and 65%, 50%, and 40% in group 2, respectively (log-rank P < .001). The median recurrence-free survival time was 8.5 months (interquartile range 6.5-11.0) in group 1 and 28.0 months (interquartile range 8.5-32.0) in group 2.


CONCLUSIONS
Proven isolation of the LAPW provides additional benefits over PVAI alone in the treatment of persistent AF and improves procedural outcome at follow-up. However, the ablation strategy of ePVAI+LAPW is still associated with a significant high incidence of very late recurrence of atrial tachyarrhythmia.


BACKGROUND
"Outcome of Atrial Fibrillation Ablation After Permanent Pulmonary Vein Antrum Isolation With or Without Proven Left Atrial Posterior Wall Isolation" (LIBERATION). ClinicalTrials.gov Identifier: NCT01660100.
Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas; Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
Rong
R
Bai
Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas; Albert Einstein College of Medicine, Montefiore Hospital, New York, New York; Department of Biomedical Engineering, University of Texas, Austin, Texas; Department of Cardiology, University of Foggia, Foggia, Italy.
Luigi
L
Di Biase
Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas.
Prasant
P
Mohanty
Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas.
Chintan
C
Trivedi
Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino IRCCS, Milan, Italy.
Antonio
A
Dello Russo
Ospedale dell'Angelo, Mestre Venice, Italy.
Sakis
S
Themistoclakis
Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino IRCCS, Milan, Italy.
Michela
M
Casella
University of Sacred Heart, Rome, Italy.
Pietro
P
Santarelli
Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino IRCCS, Milan, Italy.
Gaetano
G
Fassini
Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas.
Pasquale
P
Santangeli
Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas.
Sanghamitra
S
Mohanty
Ospedale dell'Angelo, Mestre Venice, Italy.
Antonio
A
Rossillo
University of Sacred Heart, Rome, Italy.
Gemma
G
Pelargonio
Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas.
Rodney
R
Horton
Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas.
Javier
J
Sanchez
Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas.
Joseph
J
Gallinghouse
Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas.
J David
JD
Burkhardt
Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
Chang-Sheng
CS
Ma
Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino IRCCS, Milan, Italy.
Claudio
C
Tondo
Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas; Department of Biomedical Engineering, University of Texas, Austin, Texas; California Pacific Medical Center, San Francisco, California; Dell Medical School, Austin, Texas. Electronic address: dr.natale@gmail.com.
Andrea
A
Natale
D000368:Aged; D001281:Atrial Fibrillation / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery; D017115:Catheter Ablation / Q000009:adverse effects / Q000379:methods; D017548:Echocardiography, Transesophageal / Q000379:methods; D015716:Electrocardiography, Ambulatory / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006325:Heart Atria / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000175:diagnosis / Q000517:prevention & control; D011667:Pulmonary Veins / Q000601:surgery*; D055502:Secondary Prevention / Q000379:methods / Q000706:statistics & numerical data; D016896:Treatment Outcome
Atrial fibrillation; Catheter ablation; Left atrial posterior wall; Pulmonary vein antrum isolation