Left atrial functional deterioration after beyond-pulmonary vein isolation strategy predominantly consisting of linear ablation: Insights from the EARNEST-PVI Trial

BACKGROUND Beyond-pulmonary vein isolation (PVI) strategy after initial PVI (PVI-plus) for persistent AF (PerAF) may cause greater left atrial (LA) functional deterioration than simple PVI strategy (PVI-alone). OBJECTIVE We aimed to compare post-ablation LA functional decline in patients randomized to receive either PVI-alone or PVI-plus treatments and evaluate the impact of post-ablation LA function on arrhythmia recurrence. METHODS This study is a post-hoc subanalysis of the EARNEST-PVI (NCT03514693), which randomly compared the efficacy of PVI-alone and PVI-plus strategies in patients with PerAF. Of 497 participants, we analyzed 191 patients with cardiac computed tomography-derived LA emptying fraction at three months post-ablation (LAEFpost). We compared LAEFpost between the two strategies and evaluated its association with recurrence separately in the PVI-alone and PVI-plus groups. RESULTS PVI-alone (n = 96) and PVI-plus (n = 95) groups were well-balanced. In the PVI-plus group, 99% of the patients underwent linear ablation. Of the patients with maintained sinus rhythm, LAEFpost was higher in the PVI-alone than in the PVI-plus after initial session (35.7% 29.0-41.0 vs. 31.7% 26.1-37.5, P = 0.01)-a 11.2% relative reduction. AF/AT-free survival rate after final session (median follow-up: 42 35-48 months) tended to be higher in PVI-plus (74.0% vs. 84.2%, P = 0.08). LAEFpost was associated with recurrence in the PVI-alone (hazard ratio per 10% increase: 0.60, 95% confidence interval: 0.44-0.82, P < 0.01] but not in the PVI-plus (P = 0.72). CONCLUSIONS Beyond-PVI predominantly consisting of linear ablation resulted in an 11.2% relative reduction in LAEFpost, but tended to decrease recurrence, suggesting its antiarrhythmic benefits may offset the structural compromise.