title: Left Atrial Appendage Isolation in Patients With Longstanding Persistent AF Undergoing Catheter Ablation: BELIEF Trial.
abstract: Longstanding persistent (LSP) atrial fibrillation (AF) is the most challenging type of AF. In addition to pulmonary vein isolation, substrate modification and triggers ablation have been reported to improve freedom from AF in patients with LSPAF.
  
  
  
  This study sought to assess whether the empirical electrical isolation of the left atrial appendage (LAA) could improve success at follow-up.
  
  
  
  This was an open-label, randomized study assessing the effectiveness of empirical electrical left atrial appendage isolation for the treatment of LSPAF. Patients were randomly assigned to undergo empirical electrical left atrial appendage isolation along with extensive ablation (group 1; n = 85) or extensive ablation alone (group 2; n = 88). Recurrence of atrial arrhythmias was the primary endpoint. Secondary endpoints included cardiac-related hospitalization, all-cause mortality, and stroke at follow-up.
  
  
  
  Major clinical characteristics were not different between the 2 groups. At 12-month follow-up, 48 (56%) patients in group 1 and 25 (28%) in group 2 were recurrence free after a single procedure (unadjusted hazard ratio [HR] for recurrence with standard ablation: 1.92; 95% confidence interval [CI]: 1.3 to 2.9; log-rank p = 0.001). After adjusting for age, sex, and left atrial size, standard ablation was predictive of recurrence (HR: 2.22; 95% CI: 1.29 to 3.81; p = 0.004). During repeat procedures, empirical electrical left atrial appendage isolation was performed in all patients. After an average of 1.3 procedures, cumulative success at 24-month follow-up was reported in 65 (76%) in group 1 and in 49 (56%) in group 2 (unadjusted HR: 2.24; 95% CI: 1.3 to 3.8; log-rank p = 0.003).
  
  
  
  This randomized study showed that both after a single procedure and after redo procedures in patients with LSPAF, empirical electrical isolation of the LAA improved long-term freedom from atrial arrhythmias without increasing complications. (Effect of Empirical Left Atrial Appendage Isolation on Long-term Procedure Outcome in Patients With Persistent or Longstanding Persistent Atrial Fibrillation Undergoing Catheter Ablation [BELIEF]; NCT01362738).
authors: Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas; Albert Einstein College of Medicine at 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 at St. David's Medical Center, Austin, Texas.
authors: J David
authors: JD
authors: Burkhardt
authors: Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas.
authors: Prasant
authors: P
authors: Mohanty
authors: Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas.
authors: Sanghamitra
authors: S
authors: Mohanty
authors: Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas.
authors: Javier E
authors: JE
authors: Sanchez
authors: Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas.
authors: Chintan
authors: C
authors: Trivedi
authors: Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas.
authors: Mahmut
authors: M
authors: Güneş
authors: Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas.
authors: Yalçın
authors: Y
authors: Gökoğlan
authors: Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas.
authors: Carola
authors: C
authors: Gianni
authors: Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas.
authors: Rodney P
authors: RP
authors: Horton
authors: Ospedale dell'Angelo, Mestre, Venice, Italy.
authors: Sakis
authors: S
authors: Themistoclakis
authors: Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas.
authors: G Joseph
authors: GJ
authors: Gallinghouse
authors: Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas.
authors: Shane
authors: S
authors: Bailey
authors: Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas.
authors: Jason D
authors: JD
authors: Zagrodzky
authors: California Pacific Medical Center, San Francisco, California.
authors: Richard H
authors: RH
authors: Hongo
authors: California Pacific Medical Center, San Francisco, California.
authors: Salwa
authors: S
authors: Beheiry
authors: Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas; Department of Cardiology, University of Foggia, Foggia, Italy.
authors: Pasquale
authors: P
authors: Santangeli
authors: Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino IRCCS, Milan, Italy.
authors: Michela
authors: M
authors: Casella
authors: Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino IRCCS, Milan, Italy.
authors: Antonio
authors: A
authors: Dello Russo
authors: Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas.
authors: Amin
authors: A
authors: Al-Ahmad
authors: Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas.
authors: Patrick
authors: P
authors: Hranitzky
authors: Section of Electrophysiology, University of Kansas, Kansas City, Missouri.
authors: Dhanunjaya
authors: D
authors: Lakkireddy
authors: Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino IRCCS, Milan, Italy.
authors: Claudio
authors: C
authors: Tondo
authors: Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas; Department of Biomedical Engineering, University of Texas, Austin, Texas; Division of Cardiology, Stanford University, Palo Alto, California; Section of Electrophysiology, Case Western Reserve University, Cleveland, Ohio; Interventional Electrophysiology, Scripps Clinic, San Diego, California; Department of Medicine, Dell Medical School, Austin, Texas. Electronic address: dr.natale@gmail.com.
authors: Andrea
authors: A
authors: Natale
mesh_terms: D000368:Aged; D020517:Atrial Appendage; D001281:Atrial Fibrillation / Q000601:surgery*; D006348:Cardiac Surgical Procedures / Q000379:methods; D017115:Catheter Ablation; D022062:Electrophysiologic Techniques, Cardiac; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012008:Recurrence; D013997:Time Factors
keywords: arrhythmia; atrial fibrillation; non-PV trigger; pulmonary vein; radiofrequency