What does this research mean for the field?

Pulmonary vein antrum isolation as a primary ablation strategy achieves 5-year freedom from atrial tachyarrhythmia in 58.3% of patients, with additional substrate modification providing only moderate additional benefit. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

February 2, 2016Open Access

Five-year efficacy of pulmonary vein antrum isolation as a primary ablation strategy for atrial fibrillation: a single-centre cohort study

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Atrial fibrillation (n=509). Intervention: Pulmonary vein antrum isolation (PVAI). Primary outcome: Long-term freedom from atrial tachyarrhythmia.

Key Result

Pulmonary vein antrum isolation as a primary ablation strategy achieved 5-year freedom from atrial tachyarrhythmia in 58.3% of patients, with additional substrate modification adding moderate benefit.

Study Design

Type

Cohort (n=509)

Multicenter

Structured PICO

Does pulmonary vein antrum isolation improve long-term sinus rhythm maintenance in patients with atrial fibrillation?

Population

509 consecutive patients with atrial fibrillation (mean age 57 years, 38.9% non-paroxysmal AF)

Intervention

Pulmonary vein antrum isolation (PVAI) as a primary ablation strategy, with re-PV isolation or substrate modification in redo procedures

Outcome

Long-term efficacy (restoring and maintaining long-term sinus rhythm / freedom of atrial tachyarrhythmia)

PVAI as a primary ablation strategy provides long-term freedom from atrial tachyarrhythmia in the majority of patients, with substrate modification offering only modest additional benefit while increasing the risk of atypical flutter.

Abstract

AIMS: Pulmonary vein antrum isolation (PVAI) is the cornerstone of atrial fibrillation (AF) ablation. There is an ongoing discussion on whether and when to add substrate modification to PVAI. This study evaluates (1) long-term efficacy of PVAI as a primary ablation strategy in all patients independently from AF type and (2) predictors of arrhythmia recurrence. METHODS AND RESULTS: A total of 509 consecutive patients (mean age 57 years, 38.9% non-paroxysmal AF) with AF underwent PVAI. In redo procedures, ablation was restricted to re-pulmonary vein (PV) isolation in case of PV reconnection. If the PVs were found to be isolated, substrate modification was performed. In total, 774 procedures were performed. Mean follow-up duration after the first and last ablation was, respectively, 66 ± 23 and 55 ± 25 months. A single PVAI was sufficient in restoring and maintaining long-term sinus rhythm in 41.3% (n = 210) of patients. Multiple procedures (mean 1.5) with re-PV isolation increased long-term success to 58.3% (n = 297). Additional substrate modification (n = 70) increased success to 62.5% (n = 318). After the last ablation, 87.5% of patients experienced success or significant clinical improvement on or off antiarrhythmic drugs. The incidence of left-sided atrial flutter or atrial tachycardia was 5% after PVAI and increased to 32% after additional substrate modification. Independent predictors for arrhythmia recurrence after the last ablation were non-paroxysmal AF, female sex, body mass index, hypertension, and AF duration. CONCLUSION: Five-year freedom of atrial tachyarrhythmia could be achieved by PVAI as primary ablation strategy in 58.3% of patients. Additional substrate modification only moderately increased overall success.