Impact of Left Atrial Posterior Wall Isolation Technique on the Outcome of Ablation in Persistent Atrial Fibrillation

Background Left atrial posterior wall (LAPW) isolation is an adjunct to pulmonary vein isolation (PVI) for persistent atrial fibrillation (AF). Objective To compare the effect of LAPW box isolation with LAPW point-by-point ablation and PVI in persistent AF on 12-month arrhythmia-free survival and procedure complications. Methods 77 consecutive patients who underwent LAPW box isolation, 24 patients who underwent LAPW point-by-point ablation and 101 patients who underwent PVI for persistent AF were compared. All patients had undergone no prior ablation for AF and were followed up for one year. Results Mean time to atrial tachyarrhythmia recurrence was similar with LAPW box isolation (9.8 months, 95% CI = 9-10.7) and LAPW point-by-point ablation (10 months, 95% CI = 8.6-11.3), both were longer than PVI (8.2 months, 95% CI = 7.4-9.1, log-rank p = 0.003). There was no difference in peri-procedural complications (LAPW box isolation: 5/77, LAPW point-by-point ablation: 1/24, PVI: 6/101, p = 0.91). At 12 months, no difference in atrial tachyarrhythmia recurrence was observed between box isolation (23/77, 30%) and point-bypoint ablation (11/24, 46%, p = 0.15), but significantly higher recurrence occurred with PVI alone (58/101, 57%, p < 0.001). Procedure time was similar with both approaches, with longer fluoroscopy with point-by-point ablation (median: 38 min, IQR: 29-47.75) vs box isolation (median: 28 min, IQR: 7.5-39.5, p = 0.2). Conclusion In persistent AF, there was no difference between LAPW box isolation and point-by-point ablation in terms of mean arrhythmia-free survival, 12-month recurrence or procedure complications. Arrhythmia-free survival with either technique was longer than PVI alone, with no increase in complications.