Adjunctive posterior wall isolation for the treatment of persistent and longstanding persistent atrial fibrillation (CORNERSTONE AF) trial: Design and rationale

Figures

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  Figure 1. Randomization details. For patients with persistent AF (PsAF), it will be allowed to perform the PVI by either a radiofrequency catheter or CB. Note that the operators should choose what they will use for the PVI before randomization. After the decision, randomization will be implemented before the procedure. Regarding longstanding PsAF (long‐PsAF), only a radiofrequency catheter will be permitted to be utilized for the PVI. Allocation of the patients to a PVI alone or a PVI + LAPWI will be performed in a 1:1 manner in each group, namely those with PsAF, who will undergo a PVI with a radiofrequency catheter; those with PsAF, who will undergo a PVI with a CB; and those with long‐PsAF (shown as red arrows). The large blue circles indicate CB ablation lesions and small red circles indicate radiofrequency ablation lesions. AF, atrial fibrillation; AFL, atrial flutter; AT, atrial tachycardia; CB, cryoballoon; LAPWI, left atrial posterior wall isolation; PVI, pulmonary vein isolation; RF, radiofrequency.

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  Figure 2. Ablation procedure details. (A, B) Posterior–anterior view of the voltage map (CARTO) during CS pacing after the PVI (A) and LAPWI (B) with a radiofrequency catheter in the same case. (C, D) Posterior–anterior view of the voltage map (EnsiteⅩ) during CS pacing after the PVI with a CB (C) and LAPWI with a radiofrequency catheter (D) in the same case. In each figure, the blue circles are depicted as the estimated positions of the CB, the ablation points are described as red‐colored tags, and the purple area indicates a voltage ≥0.5 mV. In the EnsiteⅩ voltage maps, the gray area indicates a voltage ≤0.1 mV, and in the CARTO voltage maps, the red area indicates a voltage ≤0.1 mV. The isolated area shown as that surrounded by the black line in each figure will be measured. CB, cryoballoon; CS, coronary sinus; LAPWI, left atrial posterior wall isolation; PVI, pulmonary vein isolation; RF, radiofrequency.

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  Figure 3. CORNERSTONE AF trial flow chart. AADs, antiarrhythmic drugs; CT, computed tomography; ECG, electrocardiography; LAPWI, left atrial posterior wall isolation; MRI, magnetic resonance imaging; PAGI‐SYM, patient assessment of upper gastrointestinal symptom severity index; PVI, pulmonary vein isolation; TTE, trans‐thoracic echocardiography.