title: Catheter Ablation of Nonparoxysmal Atrial Fibrillation Using Electrophysiologically Guided Substrate Modification During Sinus Rhythm After Pulmonary Vein Isolation.
abstract: BACKGROUND
  The high incidence of postprocedural atrial tachycardia reduces the absolute arrhythmia-free success rate of extensive ablation strategies to treat nonparoxysmal atrial fibrillation (NPAF). We hypothesized that a strategy of targeting low-voltage zones and sites with abnormal electrograms during sinus rhythm (SR-AEs) in the left atrium after circumferential pulmonary vein isolation and cavotricuspid isthmus ablation in patients with NPAF is superior.
  
  
  RESULTS
  A total of 86 consecutive patients with NPAF were enrolled in study group. After circumferential pulmonary vein isolation, cavotricuspid isthmus ablation and cardioversion to SR, high-density mapping of left atrium was performed. Areas with low-voltage zone and SR-AE were targeted for further homogenization and elimination, respectively; 78 consecutive sex- and age-matched patients with NPAF who were treated with the stepwise approach served as the historical control group. In the study group, 92% (79/86) were successfully cardioverted after circumferential pulmonary vein isolation and cavotricuspid isthmus ablation. Among the patients converted to SR, 70% (55/79) had low-voltage zone and SR-AE and received additional ablation, whereas in 30% (24/79) without SR-AE or low-voltage zone, no further ablation was performed. During a follow-up period of >30 months, the Kaplan-Meier estimated probability to maintain SR at 24 months was 69.8% versus 51.3%. And after a single procedure, 3.5% (3/86) developed postprocedural atrial tachycardia in study group, compared with 30% (24/78) in control group (P=0.0003).
  
  
  CONCLUSIONS
  A strategy of selective electrophysiologically guided atrial substrate modification in SR after circumferential pulmonary vein isolation and cavotricuspid isthmus ablation is clinically more effective than the stepwise approach for NPAF ablation.
  
  
  BACKGROUND
  URL: http://clinicaltrials.gov. Unique identifier: NCT01716143.
authors: From the Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China (G.Y., B.Y., Y.W., F.Z., W.J., H.C., M.L., K.G., Y.L., B.W., K.C., M.C.); and Cardiac Department, National University Heart Centre, Singapore, Singapore (P.K.).
authors: Gang
authors: G
authors: Yang
authors: From the Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China (G.Y., B.Y., Y.W., F.Z., W.J., H.C., M.L., K.G., Y.L., B.W., K.C., M.C.); and Cardiac Department, National University Heart Centre, Singapore, Singapore (P.K.).
authors: Bing
authors: B
authors: Yang
authors: From the Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China (G.Y., B.Y., Y.W., F.Z., W.J., H.C., M.L., K.G., Y.L., B.W., K.C., M.C.); and Cardiac Department, National University Heart Centre, Singapore, Singapore (P.K.).
authors: Youquan
authors: Y
authors: Wei
authors: From the Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China (G.Y., B.Y., Y.W., F.Z., W.J., H.C., M.L., K.G., Y.L., B.W., K.C., M.C.); and Cardiac Department, National University Heart Centre, Singapore, Singapore (P.K.).
authors: Fengxiang
authors: F
authors: Zhang
authors: From the Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China (G.Y., B.Y., Y.W., F.Z., W.J., H.C., M.L., K.G., Y.L., B.W., K.C., M.C.); and Cardiac Department, National University Heart Centre, Singapore, Singapore (P.K.).
authors: Weizhu
authors: W
authors: Ju
authors: From the Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China (G.Y., B.Y., Y.W., F.Z., W.J., H.C., M.L., K.G., Y.L., B.W., K.C., M.C.); and Cardiac Department, National University Heart Centre, Singapore, Singapore (P.K.).
authors: Hongwu
authors: H
authors: Chen
authors: From the Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China (G.Y., B.Y., Y.W., F.Z., W.J., H.C., M.L., K.G., Y.L., B.W., K.C., M.C.); and Cardiac Department, National University Heart Centre, Singapore, Singapore (P.K.).
authors: Mingfang
authors: M
authors: Li
authors: From the Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China (G.Y., B.Y., Y.W., F.Z., W.J., H.C., M.L., K.G., Y.L., B.W., K.C., M.C.); and Cardiac Department, National University Heart Centre, Singapore, Singapore (P.K.).
authors: Kai
authors: K
authors: Gu
authors: From the Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China (G.Y., B.Y., Y.W., F.Z., W.J., H.C., M.L., K.G., Y.L., B.W., K.C., M.C.); and Cardiac Department, National University Heart Centre, Singapore, Singapore (P.K.).
authors: Yazhou
authors: Y
authors: Lin
authors: From the Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China (G.Y., B.Y., Y.W., F.Z., W.J., H.C., M.L., K.G., Y.L., B.W., K.C., M.C.); and Cardiac Department, National University Heart Centre, Singapore, Singapore (P.K.).
authors: Benqi
authors: B
authors: Wang
authors: From the Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China (G.Y., B.Y., Y.W., F.Z., W.J., H.C., M.L., K.G., Y.L., B.W., K.C., M.C.); and Cardiac Department, National University Heart Centre, Singapore, Singapore (P.K.).
authors: Kejiang
authors: K
authors: Cao
authors: From the Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China (G.Y., B.Y., Y.W., F.Z., W.J., H.C., M.L., K.G., Y.L., B.W., K.C., M.C.); and Cardiac Department, National University Heart Centre, Singapore, Singapore (P.K.).
authors: Pipin
authors: P
authors: Kojodjojo
authors: From the Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China (G.Y., B.Y., Y.W., F.Z., W.J., H.C., M.L., K.G., Y.L., B.W., K.C., M.C.); and Cardiac Department, National University Heart Centre, Singapore, Singapore (P.K.). chenminglong@njmu.edu.cn.
authors: Minglong
authors: M
authors: Chen
mesh_terms: D000200:Action Potentials; D000328:Adult; D000368:Aged; D001281:Atrial Fibrillation / Q000175:diagnosis* / Q000503:physiopathology / Q000601:surgery*; D017115:Catheter Ablation / Q000009:adverse effects; D004562:Electrocardiography; D022062:Electrophysiologic Techniques, Cardiac; D005260:Female; D006339:Heart Rate; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011667:Pulmonary Veins / Q000503:physiopathology / Q000601:surgery*; D012008:Recurrence; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
keywords: atrial fibrillation; atrial tachycardia; catheter ablation; fibrosis