Circumferential pulmonary vein isolation (CPVI) with adjunctive linear ablation Vs. CPVI alone for long-standing persistent atrial fibrillation: A randomized pilot study.

This prospective randomized control trial investigated the comparative efficacy and safety of circumferential pulmonary vein isolation (CPVI) combined with modified linear ablation (CPVI-MLA) versus standalone CPVI in patients with long-standing persistent atrial fibrillation (LSPAF). In this single-center pilot trial, 134 LSPAF patients were randomized to CPVI-MLA (n = 67) or CPVI only (n = 67) groups. The CPVI-MLA protocol integrated four components: 1) ethanol infusion targeting the ligament of Marshall; 2) complete CPVI; 3) extended lesion sets (posterior wall isolation, dual isthmus ablation); and 4) substrate modification [left atrial intima adjoining coronary sinus (LAI-CS) and superior vena cava isolation (SVCI)]. 24-hour Holter monitoring was performed at the 1st, 3rd, and 6th month follow-up visits, with 7-day Holter monitoring at the 12th month follow-up visit. The primary endpoint was freedom from atrial tachyarrhythmias (≥ 30s) after the initial 3-month blanking period post-index procedure, without antiarrhythmic drugs. After a mean follow-up of 14.5 ± 9.1 months, 76.1% (51/67) in the CPVI-MLA group and 65.7% (44/67) in the CPVI only group achieved the primary endpoint (p = 0.32). However, the CPVI-MLA group demonstrated significantly higher atrial fibrillation (AF)-free survival rate (91.0% vs. 76.1%, p = 0.049), while atrial tachycardia/atrial flutter-free survival rates were comparable (83.5% vs. 88.1%, p = 0.45). The CPVI-MLA strategy required longer ablation time (68.6 ± 12.3 vs. 49.4 ± 10.3 minutes, p < 0.001) and fluoroscopy exposure (14.9 ± 9.8 vs. 9.3 ± 6.7 minutes, p < 0.001). Serious adverse events were rare and similar between groups (1.5% vs. 0%, p = 1.00). In patients with LSPAF, the CPVI-MLA strategy significantly improved freedom from AF compared to CPVI alone, although it did not improve overall sinus rhythm maintenance rate. This strategy may offer a refined approach for complex AF ablation, warranting further validation in larger trials.