Biatrial linear ablation in sustained nonpermanent AF: Results of the substrate modification with ablation and antiarrhythmic drugs in nonpermanent atrial fibrillation (SMAN-PAF) trial. Electrogram-guided substrate ablation with or without pulmonary vein isolation in patients with persistent atrial fibrillation. Substrate modification combined with pulmonary vein isolation improves outcome of catheter ablation in patients with persistent atrial fibrillation: a prospective randomized comparison. Does electrogram guided substrate ablation add to the success of pulmonary vein isolation in patients with paroxysmal atrial fibrillation? A prospective, randomized study. Substrate and Trigger Ablation for Reduction of Atrial Fibrillation (STAR AF): a randomized, multicentre, international trial† Pulmonary Vein Isolation Versus Defragmentation: The CHASE-AF Clinical Trial. Incidence and significance of early recurrences associated with different ablation strategies for AF: a STAR-AF substudy. Impact of Stepwise Ablation on the Biatrial Substrate in Patients With Persistent Atrial Fibrillation and Heart Failure Ganglionated plexus ablation vs linear ablation in patients undergoing pulmonary vein isolation for persistent/long-standing persistent atrial fibrillation: a randomized comparison. Long-term comparison of cryoballoon and radiofrequency ablation of paroxysmal atrial fibrillation: a propensity score matched analysis. Noninvasive Assessment of Atrial Substrate Change after Wide Area Circumferential Ablation: A Comparison with Segmental Pulmonary Vein Isolation
BACKGROUND More advanced atrial fibrillation ( AF ) is associated with lower success rates after pulmonary vein isolation ( PVI ) , and the optimal ablation strategy is uncertain . OBJECTIVES To assess the impact of additional linear ablation ( lines ) compared to PVI alone . METHODS In this multicenter r and omized controlled trial , 122 patients ( mean age 61.9 ± 10.5 years ; left atrial diameter 43 ± 6 mm ) with persistent AF ( PeAF ) or sustained ( > 12 hours ) paroxysmal AF ( SusPAF ) with risk factors for atrial substrate were included and followed up for 12 months . Patients were r and omized to  PVI-only or PVI + lines ( left atrial roof line , mitral isthmus line , and tricuspid isthmus line ) group . Holter monitoring was performed at 3 , 6 , and 12 months and according to symptoms . The primary outcome was atrial tachyarrhythmia recurrence lasting ≥30 seconds . RESULTS Baseline characteristics were comparable between groups ; 61 % had PeAF and 39 % SusPAF . Successful PVI was achieved for 98 % of pulmonary veins , and bidirectional block was obtained in 90 % of lines . The primary end point occurred in 38 % of the PVI + lines group and 32 % of the PVI-only group ( P = .50 ) , which was consistent in both PeAF ( 36 % vs 28 % ; P = .45 ) and SusPAF ( 42 % vs 39 % ; P = .86 ) . Compared with the PVI-only group , the PVI + lines group had higher procedure duration ( 209 ± 52 minutes vs 172 ± 44 minutes ; P < .001 ) , ablation time ( 4352 ± 1084 seconds vs 2503 ± 1061 seconds ; P < .001 ) , and radiation exposure ( Dose-area product 3992 ± 6496 Gy·cm(2 ) vs 2106 ± 1679 Gy·cm(2 ) ; P = .03 ) . Quality of life ( disease-specific Atrial Fibrillation Effect on Quality of Life question naire and mental component scale of the Short Form 36 Health Survey ) improved significantly during the study but did not differ between groups . CONCLUSION Adding lines to wide antral PVI in substrate-based AF requires significantly more ablation , increases procedure duration and radiation dose , but provides no additional clinical benefit AIMS Ablation of complex fractionated atrial electrograms ( CFAEs ) is a new approach for the treatment of atrial fibrillation ( AF ) . The purpose of the study was to assess the efficacy of CFAE ablation as a st and -alone strategy in patients with persistent AF and to compare it with a combined approach of CFAE ablation and pulmonary vein isolation ( PVI ) . METHODS AND RESULTS The study included 77 consecutive patients with persistent AF who underwent radiofrequency ( RF ) ablation of CFAE as a sole ablation procedure ( CFAE group , n = 23 patients ) or a combined approach of CFAE ablation and PVI ( CFAE plus PVI group , n = 54 patients ) . Procedures were guided by three-dimensional mapping systems . After the procedure , AF recurrences were evaluated with 7-day Holter recordings at 1 , 3 , and 6 months and every 6 months thereafter . Treatment failure was defined as > or=1 AF episode lasting > 30 s on Holter recordings during follow-up . After a mean follow-up time of 13 + /- 10 months , 2 of 23 patients ( 9 % ) with CFAE ablation and 22 of 54 patients ( 41 % ) with CFAE plus PVI were in sinus rhythm after a single ablation procedure without anti-arrhythmic medication ( P = 0.008 ) . CONCLUSION Ablation of CFAE as a st and -alone ablation strategy seems insufficient for the treatment of patients with persistent AF . Pulmonary vein isolation plus CFAE ablation significantly increases the mid-term success rate AIMS To investigate the effectiveness of additional substrate modification ( SM ) by left atrial ( LA ) linear lesions as compared with pulmonary vein isolation ( PVI ) alone in patients with persistent atrial fibrillation ( AF ) in a prospect i ve r and omized study . Percutaneous PVI has evolved as an accepted treatment for paroxysmal AF but seemed to be less effective in patients with persistent AF . The benefit of PVI alone and additional linear lesions has not been vali date d in a r and omized study so far . METHODS AND RESULTS Sixty-two patients with persistent AF ( median duration 7 , range 1 - 18 months ) were r and omly assigned to either PVI alone ( n = 30 ) or additional SM ( n = 32 ) consisting of a roof line connecting both left superior and right superior PV and LA isthmus ablation between left inferior PV and mitral annulus . Procedures including SM were performed using a three-dimensional mapping system ( EnSite NavX , St Jude Medical , St Paul , MN , USA ) . Anti-arrhythmic drugs were discontinued within 8 weeks after ablation in both groups . Follow-up included daily trans-telephonic ECG transmitted irrespective of the patient 's symptoms . PVI was successful in 98 % of all targeted veins in both groups . Additional SM did not increase fluoroscopy time ( 72.1+/-18.7 vs. 72.9+/-17.3 min , P=0.92 ) because of the use of three-dimensional navigation in the PVI+SM group . AF recurrences within the first 4 weeks following ablation were more common after PVI alone ( 77 % ) than additional SM ( 44 % , P=0.002 ) . After a follow-up time of 487 ( 429 - 570 ) days , only 20 % of patients undergoing st and alone PVI  remained in sinus rhythm when compared with 69 % following PVI combined with SM ( P=0.0001 ) . Two patients assigned to PVI+SM experienced procedure-related complications ( cardiac tamponade and minor stroke ) which resolved without sequelae . CONCLUSION PVI alone is insufficient in the treatment of persistent AF . However , additional left linear lesions increase the success rate significantly . Early AF-relapses are associated with a negative outcome after PVI alone but not following additional SM INTRODUCTION Pulmonary vein isolation ( PVI ) is an established treatment for paroxysmal atrial fibrillation ( AF ) . The ablation of complex fractionated atrial electrograms ( CFAE ) has emerged as a novel treatment approach . We sought to evaluate the additional effect of CFAE ablation to PVI in paroxysmal AF . METHODS AND RESULTS Ninety-eight patients with paroxysmal AF ( 57 + /- 10 years , 74 male ) were r and omized to the PVI ( n = 48 ) or PVI + CFAE group ( n = 50 ) . After PVI , CFAE ablation was performed in patients with inducible AF in the PVI + CFAE group . The primary endpoint was combined objective ( 7-day Holter ECG ) and subjective ( symptoms ) freedom of atrial tachyarrhythmia 3 months after ablation . Long-term follow-up ( 19 + /- 8 months ) was available in 94 of 98 patients . CFAE ablation was performed in 30 of 50 patients of the PVI + CFAE group . After 3 months , 36 of 48 patients ( 75 % ) in the PVI group and 38 of 50 patients ( 76 % ) in the PVI + CFAE group were in stable sinus rhythm ( P = NS ) . During long-term follow-up ( 19 + /- 8 months ) , 34 of 46 patients ( 74 % ) in the PVI group and 40 of 48 patients ( 83 % ) in the PVI + CFAE group were in sinus rhythm ( P = 0.08 ) . In a subgroup analysis , a significantly better long-term outcome was achieved if inducible AF after PVI had been treated by additional CFAE ablation as compared with PVI only ( sinus rhythm in 25/28 patients ; 89 % vs 22/30 patients 73 % ; P = 0.003 ) . CONCLUSION In the intention-to-treat analysis , additional CFAE ablation did not improve the success rate of PVI in patients with paroxysmal AF . However , during long-term follow-up , patients with still inducible AF after PVI seemed to profit from additional CFAE ablation Aims This multicentre , r and omized trial compared three strategies of AF ablation : ablation of complex fractionated electrograms ( CFE ) alone , pulmonary vein isolation ( PVI ) alone , and combined PVI + CFE ablation , using st and ardized automated mapping software . Methods and results Patients with drug-refractory , high-burden paroxysmal ( episodes > 6 h , > 4 in 6 months ) or persistent atrial fibrillation ( AF ) were enrolled at eight centres . Patients ( n = 100 ) were r and omized to one of three arms . For CFE alone ( n = 34 ) , spontaneous/induced AF was mapped using vali date d , automated CFE software and all sites < 120 ms were ablated until AF termination/non-inducibility . For PVI ( n = 32 ) , all four PV antra were isolated and confirmed using a circular catheter . For PVI + CFE ( n = 34 ) , all four PV antra were isolated , followed by AF induction and ablation of all CFE sites until AF termination/non-inducibility . Patients were followed at 3 , 6 , and 12 months with a visit , ECG , 48 h Holter . Atrial fibrillation symptoms were confirmed by loop recording . Repeat procedures were allowed within the first 6 months . The primary endpoint was freedom from AF > 30 s at 1 year . Patients ( age 57 ± 10 years , LA size 42 ± 6 mm ) were 35 % persistent AF . In CFE , ablation terminated AF in 68 % . Only 0.4 PVs per patient were isolated as a result of CFE . In PVI , 94 % had all four PVs successfully isolated . In PVI + CFE , 94 % had all four PVs isolated , 76 % had inducible AF with additional CFE ablation , with 73 % termination of AF . There were significantly more repeat procedures in the CFE arm ( 47 % ) vs. PVI ( 31 % ) or PVI + CFE ( 15 % ) ( P = 0.01 ) . After one procedure , PVI + CFE had a significantly higher freedom from AF ( 74 % ) compared with PVI ( 48 % ) and CFE ( 29 % ) ( P = 0.004 ) . After two procedures , PVI + CFE still had the highest success ( 88 % ) compared with PVI ( 68 % ) and CFE ( 38 % ) ( P = 0.001 ) . Ninety-six percent of these patients were off anti-arrhythmics . Complications were two tamponades , no PV stenosis , and no mortality . Conclusion In high-burden paroxysmal/persistent AF , PVI + CFE has the highest freedom from AF vs. PVI or CFE alone after one or two procedures . Complex fractionated electrogram alone has the lowest one and two procedure success rates with a higher incidence of repeat procedures . Clinical Trials.gov identifier number NCT00367757 BACKGROUND Long-term success rates using ablation for persistent atrial fibrillation ( AF ) are disappointing and usually do not exceed 60 % . OBJECTIVES This study sought to compare arrhythmia-free survival between pulmonary vein isolation ( PVI ) and a stepwise approach ( full defrag ) consisting of PVI , ablation of complex fractionated electrograms , and additional linear ablation lines in the setting of atrial tachycardias ( AT ) in patients with persistent AF after PVI . METHODS From November 2010 to February 2013 , 205 patients ( 151 men ; 61.7 ± 10.2 years of age ) underwent de novo ablation for persistent AF . Subsequently , patients were prospect ively r and omized to either PVI alone ( n = 78 ) or full defrag ( n = 75 ) , with 52 patients not r and omized due to AF termination with the original PVI . The primary endpoint was recurrence of any AT after a blanking period of 3 months . RESULTS During the entire study , 241 ablations were performed ( mean : 1.59 in the PVI-alone group , 1.55 in the full-defrag group ) . With the stepwise approach , termination of AF occurred in 45 ( 60 % ) patients . However , arrhythmia-free survival did not differ whether patients underwent single or multiple procedures ( p = 0.468 ) . Procedure duration , fluoroscopy time , and radiofrequency duration were significantly longer in the full-defrag group ( all p < 0.001 ) . CONCLUSIONS A stepwise approach aim ed at AF termination does not seem to provide additional benefit over PVI alone in patients with persistent AF , but it is associated with significantly longer procedural and fluoroscopic duration as well as radiofrequency application time . ( The R and omized Catheter Ablation of Persist End Atrial Fibrillation Study [ CHASE-AF ] ; NCT01580124 ) BACKGROUND Early recurrences of atrial tachyarrhythmias ( ERAT ) are common after  atrial fibrillation ( AF ) ablation , and predict late recurrences ( LR ) . We sought to determine the impact of different ablation strategies on ERAT and LR . METHODS AND RESULTS The STAR-AF trial r and omized 100 patients with paroxysmal or persistent AF to ablation of complex fractionated electrograms ( CFAE ) alone , pulmonary vein isolation ( PVI ) alone , or combined PVI + CFAE .  Patients were followed for 12 months . ERAT was defined as any recurrence of AF , atrial tachycardia , or flutter ( AT/AFL ) > 30 seconds during the first 3 months of follow-up . LR was defined as any recurrence of AF/AT/AFL > 30 seconds 3 - 12 months post . Forty-nine patients experienced ERAT . The index ablation strategy was the only independent predictor of ERAT on multivariate analysis ( HR 2.24 PVI vs PVI + CFAE ; and HR 2.65 CFAE vs PVI + CFAE ) . Fifty-two patients experienced LR . The presence of ERAT ( HR 3.23 ) , the use of antiarrhythmic drug ( AAD ) in the first 3 months postablation ( HR 2.85 ) , and the index ablation strategy were independently associated with LR ( HR 3.42 PVI vs PVI + CFAE ; HR 4.72 CFAE vs PVI + CFAE ) . Thirty-five of 49 ( 71 % ) patients with ERAT and 17 ( 33 % ) of 51 patients without ERAT had LR ( P < 0.0001 ) . Among patients with ERAT , increased left atrium size ( HR 1.08 ) , the use of AAD in the first 3 months postablation ( HR 2.86 ) and the index ablation strategy were independently associated with LR ( HR 4.77 PVI vs PVI + CFAE ; HR 4.45 CFAE vs PVI + CFAE ) . CONCLUSION ERAT is common following AF ablation and is strongly associated with LR . Although CFAE ablation alone results in higher rates of early and LR , the addition of CFAE to PVI results in increased long-term success without an increase in ERAT Background —Ablation of persistent atrial fibrillation can be challenging , often involving not only pulmonary vein isolation ( PVI ) but also additional linear lesions and ablation of complex fractionated electrograms ( CFE ) . We examined the impact of stepwise ablation on a human model of advanced atrial substrate of persistent atrial fibrillation in heart failure . Methods and Results —In 30 patients with persistent atrial fibrillation and left ventricular ejection fraction ⩽35 % , high-density CFE maps were recorded biatrially at baseline , in the left atrium ( LA ) after PVI and linear lesions ( roof and mitral isthmus ) , and biatrially after LA CFE ablation . Surface area of CFE ( mean cycle length ⩽120 ms ) remote to PVI and linear lesions , defined as CFE area , was reduced after PVI ( 18.3±12.03 to 10.2±7.1 cm2 ; P<0.001 ) and again after linear lesions ( 7.7±6.5 cm2 ; P=0.006 ) . Complete mitral isthmus block predicted greater CFE reduction ( P=0.02 ) . Right atrial CFE area was reduced by LA ablation , from 25.9±14.1 to 12.9±11.8 cm2 ( P<0.001 ) . Estimated 1-year arrhythmia-free survival was 72 % after a single procedure . Incomplete linear lesion block was an independent predictor of arrhythmia recurrence ( hazard ratio , 4.69 ; 95 % confidence interval , 1.05–21.06 ; P=0.04 ) . Conclusions —Remote LA CFE area was progressively reduced following PVI and linear lesions , and LA ablation reduced right atrial CFE area . Reduction of CFE area at sites remote from ablation would suggest either regression of the advanced atrial substrate or that these CFE were functional phenomena . Nevertheless , in an advanced atrial fibrillation substrate , linear lesions after PVI diminished the target area for CFE ablation , and complete lesions result ed in a favorable clinical outcome BACKGROUND The optimal ablation technique for persistent and long-st and ing persistent atrial fibrillation ( AF ) is unclear . Both linear lesion ( LL ) and ganglionated plexus ( GP ) ablation have been used in addition to pulmonary vein isolation ( PVI ) , but no direct comparison of the 2 methods exists . OBJECTIVE The aim of this study is to assess the comparative safety and efficacy of 2 different ablation strategies-PVI+LL vs PVI+GP ablation -in patients with persistent or long-st and ing persistent AF . METHODS Two hundred sixty-four consecutive patients with persistent/long-st and ing persistent AF were r and omly assigned to 2 different ablation schemes : PVI+LL ( n = 132 ) and PVI+GP ( n = 132 ) ablation . Consistent sinus rhythm ( SR ) off antiarrhythmic drug was assessed after follow-up of at least 3 years with the use of an implanted monitoring device . RESULTS All procedural end points were acutely achieved . At 12 months after a single procedure , 47 % of the patients treated with PVI+LL were in SR compared to 54 % of the patients treated with PVI+GP ( P = .29 ) . At 3 years , 34 % of the patients with PVI+LL and 49 % of the patients with PVI+GP maintained SR ( P = .035 ) . Atrial flutter was more frequent in the PVI+LL group than in PVI+GP group ( 18 % vs 6 % ; P = .002 ) . After a second procedure in 78 patients of the PVI+LL group and 55 patients of the PVI+GP group , the long-term overall success rate was 52 % and 68 % , respectively ( P = .006 ) . CONCLUSIONS PVI+GP ablation confers superior clinical results with less ablation-related left atrial flutter and reduced AF recurrence compared to PVI+LL ablation at 3 years of follow-up BACKGROUND Although radiofrequency ( RF ) and cryoballoon ( CB ) based technologies for pulmonary vein isolation ( PVI ) have both individually been demonstrated to be effective and safe for the treatment of paroxysmal AF , head-to-head comparisons are lacking . The purpose of this study was to compare the outcome of cryoballoon versus radiofrequency ablation in patients with paroxysmal atrial fibrillation undergoing pulmonary vein isolation . METHODS Out of a prospect i ve registry of 327 patients undergoing PVI , 208 patients ( age 58±11 years , ejection fraction 59±6 % , left atrial size 39±6 mm ) with paroxysmal AF were identified . The presented data set was obtained by 1:1 propensity score matching and contained 142 patients undergoing CB-PVI or RF-PVI in conjunction with a 3D mapping system , respectively . We compared single procedure efficacy of the two methods using a Cox proportional hazards model . RESULTS After a mean follow-up of 28 months and a single procedure , AF recurred in 37 of 71 ( 52 % ) in the CB-PVI group and in 31 of 71 patients ( 44 % ) in the RF-PVI group ( HR [ 95 % CI]=1.19 [ 0.74 , 1.92 ] , p=0.48 ) . Recurrence of AF for PVI using solely the CB was observed in 23 of 51 ( 45 % ) patients and in 23 of 51 ( 45 % ) patients in the corresponding RF-PVI group ( HR [ 95 % CI]=0.93 [ 0.52 , 1.66 ] , p=0.81 ) . Complication rate was not different between the groups . CONCLUSION A propensity score matched comparison between CB-PVI and RF-PVI using a 3D-mapping system for AF ablation showed similar long-term success rates Background : The wide area circumferential ablation ( WACA ) approach to atrial fibrillation is thought to result in ‘ substrate modification ’ perhaps related to autonomic denervation . We examined this prospect ively by comparing WACA and segmental pulmonary vein isolation ( PVI ) using noninvasive surrogate markers
A PVI-only strategy in PeAF patients with a low prevalence of structural heart disease using contemporary technology yields excellent outcomes comparable to those for paroxysmal AF ablation
BACKGROUND Early studies demonstrated relatively low success rates for pulmonary vein isolation ( PVI ) alone in patients with persistent atrial fibrillation ( PeAF ) .
However , the advent of new technologies and the observation that additional substrate ablation does not improve outcomes have created a new focus on PVI alone for treatment of PeAF .
OBJECTIVE The purpose of this study was to systematic ally review the recent medical literature to determine current medium-term outcomes when a PVI-only approach is used for PeAF .