title: Importance of non-pulmonary vein triggers ablation to achieve long-term freedom from paroxysmal atrial fibrillation in patients with low ejection fraction.
abstract: BACKGROUND
  Whether ablation of non-pulmonary vein (PV) triggers after pulmonary vein antrum isolation (PVAI) improves the long-term procedure outcome in patients with paroxysmal atrial fibrillation (PAF) and left ventricular systolic dysfunction is unknown.
  
  
  OBJECTIVE
  We sought to evaluate whether a more extensive ablation procedure improves outcomes at follow-up.
  
  
  METHODS
  Consecutive patients with PAF refractory to antiarrhythmic drugs presenting for PVAI were prospectively studied. Patients were categorized into 2 groups: patients with left ventricular ejection fraction (LVEF) ≤35% (group I; n = 175) and patients with LVEF ≥50% (group II; n = 545). Patients in group I were further divided according to whether additional ablation of non-PV triggers was performed (group IA; n = 88) or not (group IB; n = 87). Long-term ablation success off antiarrhythmic drugs after a single procedure was analyzed.
  
  
  RESULTS
  Patients in group I had more non-PV triggers than did patients in group II (69.1% vs 26.6%; P < .001). During a follow-up of 15.8 ± 4.7 months, fewer patients in group I remained free from recurrences than those in group II (53.7% vs 81.7%; P < .001). Long-term ablation success was higher in group IA than in group IB (75.0% vs 32.2%; P < .001) and similar to that in group II (75.0% vs 81.7%; P = .44). In multivariate analysis, LVEF ≤35% (hazard ratio 1.68; P = .003) and non-PV triggers (hazard ratio 3.12; P < .001) were independent predictors of recurrences.
  
  
  CONCLUSIONS
  In patients with PAF and left ventricular systolic dysfunction, ablation of non-PV triggers in addition to PVAI significantly improves their long-term procedure outcome.
authors: Texas Cardiac Arrhythmia Institute, St David's Medical Center, Austin, Texas; Department of Cardiology, Henan Provincial People's Hospital, Zhengzhou, Henan, China.
authors: Yonghui
authors: Y
authors: Zhao
authors: Texas Cardiac Arrhythmia Institute, 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.
authors: Luigi
authors: L
authors: Di Biase
authors: Texas Cardiac Arrhythmia Institute, St David's Medical Center, Austin, Texas.
authors: Chintan
authors: C
authors: Trivedi
authors: Texas Cardiac Arrhythmia Institute, St David's Medical Center, Austin, Texas.
authors: Sanghamitra
authors: S
authors: Mohanty
authors: Texas Cardiac Arrhythmia Institute, St David's Medical Center, Austin, Texas.
authors: Rong
authors: R
authors: Bai
authors: Texas Cardiac Arrhythmia Institute, St David's Medical Center, Austin, Texas.
authors: Prasant
authors: P
authors: Mohanty
authors: Texas Cardiac Arrhythmia Institute, St David's Medical Center, Austin, Texas.
authors: Carola
authors: C
authors: Gianni
authors: Texas Cardiac Arrhythmia Institute, St David's Medical Center, Austin, Texas.
authors: Pasquale
authors: P
authors: Santangeli
authors: Texas Cardiac Arrhythmia Institute, St David's Medical Center, Austin, Texas.
authors: Rodney
authors: R
authors: Horton
authors: Texas Cardiac Arrhythmia Institute, St David's Medical Center, Austin, Texas.
authors: Javier
authors: J
authors: Sanchez
authors: Texas Cardiac Arrhythmia Institute, St David's Medical Center, Austin, Texas.
authors: G Joseph
authors: GJ
authors: Gallinghouse
authors: Texas Cardiac Arrhythmia Institute, St David's Medical Center, Austin, Texas.
authors: Jason
authors: J
authors: Zagrodzky
authors: California Pacific Medical Center, San Francisco, California.
authors: Richard
authors: R
authors: Hongo
authors: California Pacific Medical Center, San Francisco, California.
authors: Salwa
authors: S
authors: Beheiry
authors: University of Kansas Medical Center, Kansas City, Kansas.
authors: Dhanunjaya
authors: D
authors: Lakkireddy
authors: University of Kansas Medical Center, Kansas City, Kansas.
authors: Madhu
authors: M
authors: Reddy
authors: Texas Cardiac Arrhythmia Institute, St David's Medical Center, Austin, Texas.
authors: Patrick
authors: P
authors: Hranitzky
authors: Texas Cardiac Arrhythmia Institute, St David's Medical Center, Austin, Texas.
authors: Amin
authors: A
authors: Al-Ahmad
authors: Clinical Cardiology, Gill Heart Institute, University of Kentucky, Lexington, Kentucky.
authors: Claude
authors: C
authors: Elayi
authors: Texas Cardiac Arrhythmia Institute, St David's Medical Center, Austin, Texas.
authors: J David
authors: JD
authors: Burkhardt
authors: Texas Cardiac Arrhythmia Institute, St David's Medical Center, Austin, Texas; Department of Biomedical Engineering, University of Texas, Austin, Texas; Division of Cardiology, Stanford University, Stanford, California; Case Western Reserve University, Cleveland, Ohio; California Pacific Medical Center, San Francisco, California; Interventional Electrophysiology, Scripps Clinic, San Diego, California; Dell Medical School, Austin, Texas. Electronic address: dr.natale@gmail.com.
authors: Andrea
authors: A
authors: Natale
mesh_terms: D000368:Aged; D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery; D017115:Catheter Ablation / Q000009:adverse effects / Q000379:methods; D022062:Electrophysiologic Techniques, Cardiac / Q000379:methods; D005260:Female; D006801:Humans; D000069451:Long Term Adverse Effects / Q000175:diagnosis / Q000517:prevention & control*; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D011446:Prospective Studies; D011667:Pulmonary Veins / Q000601:surgery*; D012008:Recurrence; D013318:Stroke Volume; D016896:Treatment Outcome; D018487:Ventricular Dysfunction, Left / Q000175:diagnosis / Q000503:physiopathology
chemical_list: D000889:Anti-Arrhythmia Agents
keywords: Atrial fibrillation; Catheter ablation; Ejection fraction; Heart failure