title: Randomized Study of Persistent Atrial Fibrillation Ablation: Ablate in Sinus Rhythm Versus Ablate Complex-Fractionated Atrial Electrograms in Atrial Fibrillation.
abstract: BACKGROUND
  Achieving long-term successful outcomes with ablation of persistent atrial fibrillation (AF) remains a clinical and procedural challenge. We aimed to assess 2 ablation strategies for persistent AF: pulmonary vein antral isolation (PVAI) in sinus rhythm after direct current cardioversion versus PVAI and ablation targeting complex-fractionated atrial electrograms while in AF.
  
  
  RESULTS
  Between June 2009 and July 2013, patients with continuous persistent AF for ≥3 months were prospectively randomized to either direct current cardioversion before PVAI and posterior wall/septum ablation while in sinus rhythm (group 1), versus same ablation in group 1 in addition to complex-fractionated atrial electrogram ablation while in AF (group 2). The procedural profiles and clinical outcomes of the 2 strategies were compared. Ninety patients were randomized to group 1 (n=46) or group 2 (n=44). There were no differences in baseline characteristics between groups. Over 365 days of follow-up after the index procedure, 16 patients (35%) in group 1 and 13 patients (30%) in group 2 remained arrhythmia-free off antiarrhythmic medications. Over long-term follow-up (median, 867 days), arrhythmia-free survival off antiarrhythmic medications was more likely in group 1 than in group 2 in Kaplan-Meier analysis (Log Rank P=0.04). Group 1 ablation was associated with significantly shorter procedural duration and fluoroscopy time (231±72 versus 273±76 min; P=0.008 and 54 [Q1-Q3: 46-67] versus 66 (Q1-Q3: 53-83] min; P=0.018, respectively).
  
  
  CONCLUSIONS
  In patients with persistent AF, PVAI in sinus rhythm after direct current cardioversion is associated with higher success and shorter procedural and fluoroscopy times compared with PVAI in AF with additional complex-fractionated atrial electrogram ablation.
  
  
  BACKGROUND
  URL: http://www.clinicaltrials.gov. Unique identifier: NCT02429648.
authors: From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH.
authors: Mohamed
authors: M
authors: Bassiouny
authors: From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH.
authors: Walid
authors: W
authors: Saliba
authors: From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH.
authors: Ayman
authors: A
authors: Hussein
authors: From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH.
authors: John
authors: J
authors: Rickard
authors: From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH.
authors: Mariam
authors: M
authors: Diab
authors: From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH.
authors: Wahaj
authors: W
authors: Aman
authors: From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH.
authors: Thomas
authors: T
authors: Dresing
authors: From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH.
authors: Thomas
authors: T
authors: Callahan
authors: From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH.
authors: Mandeep
authors: M
authors: Bhargava
authors: From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH.
authors: David O
authors: DO
authors: Martin
authors: From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH.
authors: Mingyuan
authors: M
authors: Shao
authors: From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH.
authors: Bryan
authors: B
authors: Baranowski
authors: From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH.
authors: Khaldoun
authors: K
authors: Tarakji
authors: From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH.
authors: Patrick J
authors: PJ
authors: Tchou
authors: From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH.
authors: Ali
authors: A
authors: Hakim
authors: From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH.
authors: Mohamed
authors: M
authors: Kanj
authors: From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH.
authors: Bruce
authors: B
authors: Lindsay
authors: From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH. waznio@ccf.org.
authors: Oussama
authors: O
authors: Wazni
mesh_terms: D000200:Action Potentials; 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*; D018572:Disease-Free Survival; D015716:Electrocardiography, Ambulatory; D022062:Electrophysiologic Techniques, Cardiac; D005260:Female; D005471:Fluoroscopy; D006329:Heart Conduction System / Q000503:physiopathology / Q000601:surgery*; D006339:Heart Rate; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009820:Ohio; D061646:Operative Time; D011237:Predictive Value of Tests; D011446:Prospective Studies; D015641:Radiography, Interventional / Q000379:methods; D012008:Recurrence; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000889:Anti-Arrhythmia Agents
keywords: atrial fibrillation; catheter ablation; fluoroscopy; pulmonary veins