title: Pulmonary Vein Antral Isolation and Nonpulmonary Vein Trigger Ablation Are Sufficient to Achieve Favorable Long-Term Outcomes Including Transformation to Paroxysmal Arrhythmias in Patients With Persistent and Long-Standing Persistent Atrial Fibrillation.
abstract: Transformation from persistent to paroxysmal atrial fibrillation (AF) after ablation suggests modification of the underlying substrate. We examined the nature of initial arrhythmia recurrence in patients with nonparoxysmal AF undergoing antral pulmonary vein isolation and nonpulmonary vein trigger ablation and correlated recurrence type with long-term ablation efficacy after the last procedure.
  
  
  
  Three hundred and seventeen consecutive patients with persistent (n=200) and long-standing persistent (n=117) AF undergoing first ablation were included. AF recurrence was defined as early (≤6 weeks) or late (>6 weeks after ablation) and paroxysmal (either spontaneous conversion or treated with cardioversion ≤7 days) or persistent (lasting >7 days). During median follow-up of 29.8 (interquartile range: 14.8-49.9) months, 221 patients had ≥1 recurrence. Initial recurrence was paroxysmal in 169 patients (76%) and persistent in 52 patients (24%). Patients experiencing paroxysmal (versus persistent) initial recurrence were more likely to achieve long-term freedom off antiarrhythmic drugs (hazard ratio, 2.2; 95% confidence interval, 1.5-3.2; P<0.0001), freedom on/off antiarrhythmic drugs (hazard ratio, 2.5; 95% confidence interval, 1.6-3.8; P<0.0001), and arrhythmia control (hazard ratio, 5.2; 95% confidence interval, 2.9-9.2; P<0.0001) after last ablation.
  
  
  
  In patients with persistent and long-standing persistent AF, limited ablation targeting pulmonary veins and documented nonpulmonary vein triggers improves the maintenance of sinus rhythm and reverses disease progression. Transformation to paroxysmal AF after initial ablation may be a step toward long-term freedom from recurrent arrhythmia.
authors: From the Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia (J.J.L., D.M., R.K.P., P.S., E.S.Z., D.S.F., G.E.S., R.D.S., R.D., F.C.G., D.L., M.D.H., M.P.R., D.J.C., F.E.M., S.D.); and Department of Medicine, Johns Hopkins University, Baltimore, MD (M.A.E.).
authors: Jackson J
authors: JJ
authors: Liang
authors: From the Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia (J.J.L., D.M., R.K.P., P.S., E.S.Z., D.S.F., G.E.S., R.D.S., R.D., F.C.G., D.L., M.D.H., M.P.R., D.J.C., F.E.M., S.D.); and Department of Medicine, Johns Hopkins University, Baltimore, MD (M.A.E.).
authors: Melissa A
authors: MA
authors: Elafros
authors: From the Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia (J.J.L., D.M., R.K.P., P.S., E.S.Z., D.S.F., G.E.S., R.D.S., R.D., F.C.G., D.L., M.D.H., M.P.R., D.J.C., F.E.M., S.D.); and Department of Medicine, Johns Hopkins University, Baltimore, MD (M.A.E.).
authors: Daniele
authors: D
authors: Muser
authors: From the Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia (J.J.L., D.M., R.K.P., P.S., E.S.Z., D.S.F., G.E.S., R.D.S., R.D., F.C.G., D.L., M.D.H., M.P.R., D.J.C., F.E.M., S.D.); and Department of Medicine, Johns Hopkins University, Baltimore, MD (M.A.E.).
authors: Rajeev K
authors: RK
authors: Pathak
authors: From the Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia (J.J.L., D.M., R.K.P., P.S., E.S.Z., D.S.F., G.E.S., R.D.S., R.D., F.C.G., D.L., M.D.H., M.P.R., D.J.C., F.E.M., S.D.); and Department of Medicine, Johns Hopkins University, Baltimore, MD (M.A.E.).
authors: Pasquale
authors: P
authors: Santangeli
authors: From the Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia (J.J.L., D.M., R.K.P., P.S., E.S.Z., D.S.F., G.E.S., R.D.S., R.D., F.C.G., D.L., M.D.H., M.P.R., D.J.C., F.E.M., S.D.); and Department of Medicine, Johns Hopkins University, Baltimore, MD (M.A.E.).
authors: Erica S
authors: ES
authors: Zado
authors: From the Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia (J.J.L., D.M., R.K.P., P.S., E.S.Z., D.S.F., G.E.S., R.D.S., R.D., F.C.G., D.L., M.D.H., M.P.R., D.J.C., F.E.M., S.D.); and Department of Medicine, Johns Hopkins University, Baltimore, MD (M.A.E.).
authors: David S
authors: DS
authors: Frankel
authors: From the Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia (J.J.L., D.M., R.K.P., P.S., E.S.Z., D.S.F., G.E.S., R.D.S., R.D., F.C.G., D.L., M.D.H., M.P.R., D.J.C., F.E.M., S.D.); and Department of Medicine, Johns Hopkins University, Baltimore, MD (M.A.E.).
authors: Gregory E
authors: GE
authors: Supple
authors: From the Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia (J.J.L., D.M., R.K.P., P.S., E.S.Z., D.S.F., G.E.S., R.D.S., R.D., F.C.G., D.L., M.D.H., M.P.R., D.J.C., F.E.M., S.D.); and Department of Medicine, Johns Hopkins University, Baltimore, MD (M.A.E.).
authors: Robert D
authors: RD
authors: Schaller
authors: From the Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia (J.J.L., D.M., R.K.P., P.S., E.S.Z., D.S.F., G.E.S., R.D.S., R.D., F.C.G., D.L., M.D.H., M.P.R., D.J.C., F.E.M., S.D.); and Department of Medicine, Johns Hopkins University, Baltimore, MD (M.A.E.).
authors: Rajat
authors: R
authors: Deo
authors: From the Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia (J.J.L., D.M., R.K.P., P.S., E.S.Z., D.S.F., G.E.S., R.D.S., R.D., F.C.G., D.L., M.D.H., M.P.R., D.J.C., F.E.M., S.D.); and Department of Medicine, Johns Hopkins University, Baltimore, MD (M.A.E.).
authors: Fermin C
authors: FC
authors: Garcia
authors: From the Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia (J.J.L., D.M., R.K.P., P.S., E.S.Z., D.S.F., G.E.S., R.D.S., R.D., F.C.G., D.L., M.D.H., M.P.R., D.J.C., F.E.M., S.D.); and Department of Medicine, Johns Hopkins University, Baltimore, MD (M.A.E.).
authors: David
authors: D
authors: Lin
authors: From the Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia (J.J.L., D.M., R.K.P., P.S., E.S.Z., D.S.F., G.E.S., R.D.S., R.D., F.C.G., D.L., M.D.H., M.P.R., D.J.C., F.E.M., S.D.); and Department of Medicine, Johns Hopkins University, Baltimore, MD (M.A.E.).
authors: Mathew D
authors: MD
authors: Hutchinson
authors: From the Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia (J.J.L., D.M., R.K.P., P.S., E.S.Z., D.S.F., G.E.S., R.D.S., R.D., F.C.G., D.L., M.D.H., M.P.R., D.J.C., F.E.M., S.D.); and Department of Medicine, Johns Hopkins University, Baltimore, MD (M.A.E.).
authors: Michael P
authors: MP
authors: Riley
authors: From the Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia (J.J.L., D.M., R.K.P., P.S., E.S.Z., D.S.F., G.E.S., R.D.S., R.D., F.C.G., D.L., M.D.H., M.P.R., D.J.C., F.E.M., S.D.); and Department of Medicine, Johns Hopkins University, Baltimore, MD (M.A.E.).
authors: David J
authors: DJ
authors: Callans
authors: From the Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia (J.J.L., D.M., R.K.P., P.S., E.S.Z., D.S.F., G.E.S., R.D.S., R.D., F.C.G., D.L., M.D.H., M.P.R., D.J.C., F.E.M., S.D.); and Department of Medicine, Johns Hopkins University, Baltimore, MD (M.A.E.).
authors: Francis E
authors: FE
authors: Marchlinski
authors: From the Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia (J.J.L., D.M., R.K.P., P.S., E.S.Z., D.S.F., G.E.S., R.D.S., R.D., F.C.G., D.L., M.D.H., M.P.R., D.J.C., F.E.M., S.D.); and Department of Medicine, Johns Hopkins University, Baltimore, MD (M.A.E.). sanjay.dixit@uphs.upenn.edu.
authors: Sanjay
authors: S
authors: Dixit
mesh_terms: D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use; D000925:Anticoagulants / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000188:drug therapy / Q000601:surgery*; D017115:Catheter Ablation / Q000379:methods*; D003131:Combined Modality Therapy; D018450:Disease Progression; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011667:Pulmonary Veins / Q000601:surgery*; D012008:Recurrence; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome
chemical_list: D000889:Anti-Arrhythmia Agents; D000925:Anticoagulants
keywords: atrial fibrillation; catheter ablation; pulmonary vein; recurrence