P887Pulmonary vein isolation vs. additional linear ablation for patients with persistent atrial fibrillation those changed to paroxysmal type with antiarrhythmic therapy: a multi-center randomized study

While pulmonary vein isolation (PVI) remains the cornerstone for invasive treatment of atrial fibrillation (AF), patients with persistent AF still have a high rate of recurrence with this method. Stochastic Trajectory Analysis of Ranked signals (STAR) mapping uses data from multiple individual wavefronts during ongoing AF to identify local drivers of persistent AF. In this non-randomized study, STAR mapping and ablation showed significantly lower recurrence of atrial arrhythmias compared to a consecutive PVI-only cohort and a propensity-matched ‘conventional ablation’ cohort (consisting of PVI plus complex fractionated atrial electrogram ablation or linear ablation). This benefit was driven by a much lower rate of AF recurrence in the STAR (6.2%) cohort vs PVI-only (44%) or ‘conventional’ (40%) with no significant difference in atrial tachycardia recurrence. Additionally, AF termination rates during ablation were approximately three times higher in the STAR cohort. While the analysis is retrospective and not randomized, the STAR cohort was also the only cohort with complete cessation of anti-arrhythmic drugs at three months and Holter monitoring at 6 and 12 months post-ablation per protocol. While STAR mapping appears to be a very promising new tool for treating persistent AF, history predicts at least some regression to the mean when future randomized comparisons are made. The authors have planned a multicenter randomized trial of PVI plus STAR mapping vs PVI-only for persistent AF. The global community of electrophysiologists and patients with AF eagerly awaits the results.

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Commentary: Virtual In-Silico Modeling Guided Catheter Ablation Predicts Effective Linear Ablation Lesion Set for Longstanding Persistent Atrial Fibrillation: Multicenter Prospective Randomized Study

Frontiers in Physiology ◽

10.3389/fphys.2017.01113 ◽

2017 ◽

Vol 8 ◽

Cited By ~ 1

Author(s):

Axel Loewe ◽

Olaf Dössel

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

In Silico ◽

Randomized Study ◽

Persistent Atrial Fibrillation ◽

Prospective Randomized Study ◽

Ablation Lesion ◽

In Silico Modeling ◽

Linear Ablation

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Abstract 17457: Does Additional Complex Fractionated Atrial Elecrogram Guided Ablation After Linear Ablation Improve Clinical Outcome of Catheter Ablation for Longstanding Persistent Atrial Fibrillation? A Prospective Randomized Study

Circulation ◽

10.1161/circ.132.suppl_3.17457 ◽

2015 ◽

Vol 132 (suppl_3) ◽

Author(s):

Tae-Hoon Kim ◽

Jae-Sun Uhm ◽

Jong-Youn Kim ◽

Boyoung Joung ◽

Moon-Hyoung Lee ◽

...

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Clinical Outcome ◽

Randomized Study ◽

Persistent Atrial Fibrillation ◽

Related Complication ◽

Recurrence Rates ◽

Clinical Recurrence ◽

Linear Ablation ◽

Improve Clinical Outcome

Introduction: Although long-lasting circumferential pulmonary vein isolation (CPVI) is a corner stone of catheter ablation for atrial fibrillation (AF), it is not clear whether additional linear or complex fractionated atrial electrogram (CFAE)-guided ablations improve clinical outcome in patients with long-standing persistent AF (L-PeAF). Hypothesis: The purposes of this study were to compare CFAE maps before and after linear ablation, and to test whether additional CFAE ablation after linear ablation improves clinical outcome of L-PeAF. Methods: This study enrolled 119 consecutive L-PeAF patients (male 72.8%, 61.7±10.6 years old) who underwent RFCA. After baseline CFAE mapping, we conducted CPVI and linear ablations (posterior box lesion and anterior line). If AF maintained after linear ablation, we mapped CFAE again, and randomly assigned the patients to linear ablation group (Line, n=45) and additional CFAE ablation group (CFAE+Line, n=48). The patients whose AF terminated or changed to AT were excluded from randomization and classified as AF-Stop group (n=26). We compared pre- and post-linear ablation CFAE maps and clinical outcomes of CFAE+Line, Line, and AF-Stop groups. Results: 1. Mean CFAE-cycle length (CL) was significantly prolonged (203.65±40.35 ms to 264.17±39.03 ms, p<0.001) and CFAE area was reduced (15.49±14.95% to 7.95±9.36%, p<0.001) after linear ablation. Post-linear ablation CFAE was mainly located at left atrial (LA) appendage, septum, and posterior inferior LA. 2. There were no differences in total procedure time (p=0.441), ablation time (p=0.144), and procedure-related complication rate (p=0.955) among three groups. 3. During 17.4±10.5 month follow-up period, clinical recurrence rates were 30.4% in CFAE+Line group, 12.8% in Line group, and 16.7% in AF-Stop groups, respectively (Log rank, p=0.138). 4. Additional CFAE ablation after linear ablation did not improve clinical outcome of catheter ablation at all in patients with L-PeAF (HR 2.11, 95% CI 0.91 - 4.89, p=0.082). Conclusions: Linear ablation prolonged CFAE-CL and localized CFAE area in patients with L-PeAF. However, CFAE guided ablation in addition to linear ablation and CPVI did not improve clinical outcome of catheter ablation.

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