title: Biatrial linear ablation in sustained nonpermanent AF: Results of the substrate modification with ablation and antiarrhythmic drugs in nonpermanent atrial fibrillation (SMAN-PAF) trial.
abstract: BACKGROUND
  More advanced atrial fibrillation (AF) is associated with lower success rates after pulmonary vein isolation (PVI), and the optimal ablation strategy is uncertain.
  
  
  OBJECTIVE
  To assess the impact of additional linear ablation (lines) compared to PVI alone.
  
  
  METHODS
  In this multicenter randomized controlled trial, 122 patients (mean age 61.9 ± 10.5 years; left atrial diameter 43 ± 6 mm) with persistent AF (PeAF) or sustained (>12 hours) paroxysmal AF (SusPAF) with risk factors for atrial substrate were included and followed up for 12 months. Patients were randomized to PVI-only or PVI + lines (left atrial roof line, mitral isthmus line, and tricuspid isthmus line) group. Holter monitoring was performed at 3, 6, and 12 months and according to symptoms. The primary outcome was atrial tachyarrhythmia recurrence lasting ≥30 seconds.
  
  
  RESULTS
  Baseline characteristics were comparable between groups; 61% had PeAF and 39% SusPAF. Successful PVI was achieved for 98% of pulmonary veins, and bidirectional block was obtained in 90% of lines. The primary end point occurred in 38% of the PVI + lines group and 32% of the PVI-only group (P = .50), which was consistent in both PeAF (36% vs 28%; P = .45) and SusPAF (42% vs 39%; P = .86). Compared with the PVI-only group, the PVI + lines group had higher procedure duration (209 ± 52 minutes vs 172 ± 44 minutes; P < .001), ablation time (4352 ± 1084 seconds vs 2503 ± 1061 seconds; P < .001), and radiation exposure (Dose-area product 3992 ± 6496 Gy·cm(2) vs 2106 ± 1679 Gy·cm(2); P = .03). Quality of life (disease-specific Atrial Fibrillation Effect on Quality of Life questionnaire and mental component scale of the Short Form 36 Health Survey) improved significantly during the study but did not differ between groups.
  
  
  CONCLUSIONS
  Adding lines to wide antral PVI in substrate-based AF requires significantly more ablation, increases procedure duration and radiation dose, but provides no additional clinical benefit.
authors.affiliation: Institute of Cardiovascular Medicine and Science, Liverpool & London, United Kingdom; Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; Imperial College London, London, United Kingdom.
authors.forename: Gareth J
authors.initials: GJ
authors.lastname: Wynn
authors.affiliation: Institute of Cardiovascular Medicine and Science, Liverpool & London, United Kingdom; Imperial College London, London, United Kingdom; Royal Brompton Hospital, London, United Kingdom; Harefield Hospital, London, United Kingdom.
authors.forename: Sandeep
authors.initials: S
authors.lastname: Panikker
authors.affiliation: Institute of Cardiovascular Medicine and Science, Liverpool & London, United Kingdom; Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.
authors.forename: Maureen
authors.initials: M
authors.lastname: Morgan
authors.affiliation: Institute of Cardiovascular Medicine and Science, Liverpool & London, United Kingdom; Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.
authors.forename: Mark
authors.initials: M
authors.lastname: Hall
authors.affiliation: Institute of Cardiovascular Medicine and Science, Liverpool & London, United Kingdom; Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.
authors.forename: Johan
authors.initials: J
authors.lastname: Waktare
authors.affiliation: Institute of Cardiovascular Medicine and Science, Liverpool & London, United Kingdom; Imperial College London, London, United Kingdom; Royal Brompton Hospital, London, United Kingdom; Harefield Hospital, London, United Kingdom.
authors.forename: Vias
authors.initials: V
authors.lastname: Markides
authors.affiliation: Institute of Cardiovascular Medicine and Science, Liverpool & London, United Kingdom; Imperial College London, London, United Kingdom; Harefield Hospital, London, United Kingdom.
authors.forename: Wajid
authors.initials: W
authors.lastname: Hussain
authors.affiliation: Institute of Cardiovascular Medicine and Science, Liverpool & London, United Kingdom; Imperial College London, London, United Kingdom; Royal Brompton Hospital, London, United Kingdom.
authors.forename: Tushar
authors.initials: T
authors.lastname: Salukhe
authors.affiliation: Institute of Cardiovascular Medicine and Science, Liverpool & London, United Kingdom; Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.
authors.forename: Simon
authors.initials: S
authors.lastname: Modi
authors.affiliation: Institute of Cardiovascular Medicine and Science, Liverpool & London, United Kingdom; Imperial College London, London, United Kingdom; Royal Brompton Hospital, London, United Kingdom.
authors.forename: Julian
authors.initials: J
authors.lastname: Jarman
authors.affiliation: Institute of Cardiovascular Medicine and Science, Liverpool & London, United Kingdom; Imperial College London, London, United Kingdom; Harefield Hospital, London, United Kingdom.
authors.forename: David G
authors.initials: DG
authors.lastname: Jones
authors.affiliation: Institute of Cardiovascular Medicine and Science, Liverpool & London, United Kingdom; Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.
authors.forename: Richard
authors.initials: R
authors.lastname: Snowdon
authors.affiliation: Institute of Cardiovascular Medicine and Science, Liverpool & London, United Kingdom; Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; Imperial College London, London, United Kingdom.
authors.forename: Derick
authors.initials: D
authors.lastname: Todd
authors.affiliation: Institute of Cardiovascular Medicine and Science, Liverpool & London, United Kingdom; Imperial College London, London, United Kingdom; Royal Brompton Hospital, London, United Kingdom; Harefield Hospital, London, United Kingdom.
authors.forename: Tom
authors.initials: T
authors.lastname: Wong
authors.affiliation: Institute of Cardiovascular Medicine and Science, Liverpool & London, United Kingdom; Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; Imperial College London, London, United Kingdom. Electronic address: Dhiraj.gupta@lhch.nhs.uk.
authors.forename: Dhiraj
authors.initials: D
authors.lastname: Gupta
mesh_terms: D000368:Aged; D000889:Anti-Arrhythmia Agents / Q000008:administration & dosage*; D001281:Atrial Fibrillation / Q000175:diagnosis / Q000503:physiopathology / Q000523:psychology / Q000601:surgery; D017115:Catheter Ablation / Q000009:adverse effects / Q000379:methods; D015716:Electrocardiography, Ambulatory / Q000379:methods; D022062:Electrophysiologic Techniques, Cardiac / Q000379:methods; D005260:Female; D006325:Heart Atria / Q000503:physiopathology / Q000601:surgery; D006801:Humans; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D018579:Patient Selection; D011184:Postoperative Period; D011667:Pulmonary Veins / Q000601:surgery*; D011788:Quality of Life; D012008:Recurrence
chemical_list: D000889:Anti-Arrhythmia Agents
keywords: Ablation; Atrial Fibrillation; Atrial substrate; Clinical trial; Outcomes; Persistent atrial fibrillation; Quality of life