A multicentre study on persistent atrial fibrillation ablation targeting rotational activity on top of pulmonary vein isolation: insights from an extensive mapping technique

Marco Scaglione; Francesco Geuna; Enrico Guido Spinoni; Andrea Lamanna; F Bulian; Francesco Solimene; Ricarda Marinigh; Vincenzo Schillaci; Alberto Battaglia; Alberto Arestia; Maurizio Del Greco; Marco Gagliardi; Massimiliano Maines; Giulio Zucchelli; Francesco Pentimalli; Natascia Cerrato; Giuseppe Stabile; Giuseppe Allocca; Domenico Caponi; Roberto Mantovan

doi:10.3389/fcvm.2026.1746001

Figures

Why the study?

Rotational activity has been proposed as etiopathogenetic in AF, but its presence, distribution, response to PVI, and the outcome of its elimination remained to be evaluated.

Does a tailored ablation strategy targeting rotational activity (identified by CARTO Finder) on top of pulmonary vein isolation improve sinus rhythm maintenance compared to standard pulmonary vein isolation plus empirical linear ablation in patients with persistent atrial fibrillation?

Structured PICO

Does a tailored ablation strategy targeting rotational activity (identified by CARTO Finder) on top of pulmonary vein isolation improve sinus rhythm maintenance compared to standard pulmonary vein isolation plus empirical linear ablation in patients with persistent atrial fibrillation?

P

Population

132 consecutive adult patients (n=76 in the study group, n=56 in the control group) undergoing their first transcatheter ablation for symptomatic persistent atrial fibrillation (episode lasting >1 week and <1 year) across 7 Italian electrophysiology laboratories between October 2020 and March 2022. Study group mean age 63 ± 8 years, 81% male; control group mean age 60 ± 5.9 years, 78.6% male, median CHADS-VA score 2 (IQR 0-5). Exclusions: sinus rhythm at time of ablation, age <18 years, previous AF ablation, severe valvular defects, or programmed cardiac surgical intervention.

I

Intervention

Tailored transcatheter radiofrequency ablation strategy using the CARTO3 mapping system and Pentaray catheter: Step 1 electroanatomical mapping with CARTO Finder algorithm to identify rotational activity (RotAct), Step 2 pulmonary vein isolation (PVI) using Smart Touch, Smart Touch SF, or QDOT Micro catheters, Step 3 remapping with CARTO Finder, Step 4 additional linear ablation lines to intersect residual RotAct areas (connecting to scar or anatomical boundaries), and Step 5 remapping to confirm complete RotAct elimination. Oral anticoagulation was uninterrupted.

C

Comparator

Standard transcatheter ablation protocol using CARTO3 mapping system consisting of pulmonary vein isolation (PVI) plus adjunctive linear ablation lesions (posterior wall/box, left atrial roof, mitral isthmus, anterior wall) applied at the physician's discretion based on substrate remodeling and AF persistence after PVI (n=56).

O

Outcome

Presence and distribution of rotational activity (RotAct) in persistent AF; influence of PVI on RotAct; sinus rhythm maintenance (freedom from arrhythmia relapse) with or without antiarrhythmic drugs during follow-up (mean 13 ± 6 months in study group, 13 ± 5 months in control group, after a 3-month blanking period) comparing the tailored RotAct ablation group, standard ablation control group, and subgroups (structural heart disease GI vs GII, and baseline RotAct R+ vs R-).surrogate

In patients with persistent atrial fibrillation, pulmonary vein isolation significantly modifies rotational activity, and a tailored ablation strategy targeting residual rotational activity mapped by CARTO Finder achieves higher sinus rhythm maintenance (91.5%) compared to standard PVI plus empirical linear ablation (78.6%).

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Implication

May support rotational activity mapping to augment PVI success in persistent AF; leaves open confirmation versus PVI alone in randomized trials.

Abstract

Background-aims: Recently, the etiopathogenetic role of rotational activity (RotAct) in atrial fibrillation (AF) has been proposed. We designed a prospective multicenter study using CARTO Finder to evaluate the presence/distribution of RotActs in persistent AF (persAF), pulmonary vein isolation (PVI)influences on RotActs, and the impact of its elimination on top of PVI on procedural outcomes. Methods: For this study, 76 patients with pers AF ablation were enrolled. Procedural steps involved (1) using a CARTO-Finder map to look for RotActs (physician blinded); (2) PVI; (3) using a new map to look for residual/new RotActs; (4) ablation of RotActs, if present; (5) and finally using a new map to confirm RotAct elimination. Populations were divided based on the presence or absence of structural heart disease (Group I and II) and the presence or absence (R+ and R-) of RotActs before PVI. Presence, number, and distribution of RotAct at STEP 1, the impact of PVI on RotAct at STEP 3, and maintenance of sinus rhythm (SR) during follow-up were evaluated. 56 AF patients undergoing standard ablation protocol were included as a control group. Conclusion: RotAct was present in 38% in persAF patients. PVI influenced the number and distribution of RotActs. A tailored ablation strategy provided a high success rate (91.5%) at the follow-up.

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Cite This Study

Scaglione et al. (2026) studied this question.

synapsesocial.com/papers/69f935218338827971878bcd https://doi.org/10.3389/fcvm.2026.1746001

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A multicentre study on persistent atrial fibrillation ablation targeting rotational activity on top of pulmonary vein isolation: insights from an extensive mapping technique

Figures

Structured PICO

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

A multicentre study on persistent atrial fibrillation ablation targeting rotational activity on top of pulmonary vein isolation: insights from an extensive mapping technique

Figures

Structured PICO

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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