Persistent atrial fibrillation presenting in sinus rhythm: Pulmonary vein isolation versus pulmonary vein isolation plus electrogram-guided ablation

• Published in: Archives of cardiovascular diseases 2013-10, Vol.106 (10), p.501-510
• Main Authors: Sebag, Frederic A, Chaachoui, Najia, Linton, Nick W, Amraoui, Sana, Harrison, James, Williams, Steven, Rinaldi, Aldo C, Gill, Jaswinder, Cooklin, Michael, Kirubakaran, Senthil, O’Neill, Mark D, Wright, Matthew, Lellouche, Nicolas
• Format: Article
• Language: English
• Subjects: Ablation de fibrillation atriale; Ablation de substrat atrial; Aged; Atrial Fibrillation - diagnosis; Atrial Fibrillation - physiopathology; Atrial Fibrillation - surgery; Atrial fibrillation ablation; Cardiovascular; Catheter Ablation - adverse effects; Catheter Ablation - methods; Electrogram-based ablation; Electrophysiologic Techniques, Cardiac; Female; Fibrillation atriale persistante; France; Humans; Internal Medicine; Isolation des veines pulmonaires; London; Male; Middle Aged; Persistent atrial fibrillation; Predictive Value of Tests; Pulmonary vein isolation; Pulmonary Veins - physiopathology; Pulmonary Veins - surgery; Recurrence; Retrospective Studies; Time Factors; Treatment Outcome
• ISSN: 1875-2136; 1875-2128
• DOI: 10.1016/j.acvd.2013.06.048

Summary Background The classification of atrial fibrillation as paroxysmal or persistent (PsAF) is clinically useful, but does not accurately reflect the underlying pathophysiology and is therefore a suboptimal guide to selection of ablation strategy. Aim To determine if additional substrate ablation is beneficial for a subset of patients with PsAF, in whom long periods of sinus rhythm (SR) can be maintained. Methods We included patients presenting with PsAF in whom continuous periods of SR > 3 months were documented. All patients were in SR on the day of the procedure. Electrical pulmonary vein isolation (PVI) was performed in all patients. Additional electrogram (EGM)-guided ablation was left to the discretion of the operator. Patient characteristics and follow-up were analysed with respect to presence or absence of additional EGM-guided ablation. Results Sixty-five patients (mean age 60.1 ± 8.9 years; 81.5% men) met the inclusion criteria. EGM-guided ablation was performed in 32 (49%) patients. Patients with and without EGM-guided ablation had similar baseline characteristics. Absence of EGM-guided ablation was one of the independent predictors for arrhythmia recurrences after the index procedure (hazard ratio 0.24; confidence interval 0.12–0.47). After a median follow-up of 18 ± 10 months, the number of procedures required was significantly higher in the ‘PVI-only’ group (2.24 ± 0.75 vs. 1.84 ± 0.81; P = 0.04) to achieve a similar success rate (84% vs. 81%; P = 0.833). Conclusion The addition of EGM-guided ablation requires fewer procedures to achieve similar clinical efficacy in mid-term follow-up compared with a PVI-only strategy in patients with PsAF presenting for ablation in SR.