Pulmonary vein isolation plus left atrial posterior wall isolation and additional nonpulmonary vein trigger ablation using high‐dose isoproterenol for long‐standing persistent atrial fibrillation

BACKGROUND: Little evidence exists regarding the endpoint and optimum approach to catheter ablation for long-standing persistent atrial fibrillation (LSPAF). We examined the efficacy of pulmonary vein isolation (PVI) plus left atrium posterior wall isolation (PWI) and additional non-PV trigger ablation using high-dose isoproterenol for LSPAF. METHODS: One-hundred and fifty-five patients (median AF duration, 36 months) underwent catheter ablation for LSPAF; After PVI plus PWI, they underwent provocation of non-PV triggers by high-dose isoproterenol and were divided into 3 groups based on the results: group A, PVI plus PWI alone, without induced non-PV triggers (single procedure: 105 patients, multiple procedures: 90 patients); group B, mappable non-PV triggers demonstrated and ablated (single procedure: 41 patients, multiple procedures: 45 patients); group C, if non-PV triggers were unmappable or could not be induced in repeated procedures, adjunctive complex fractionated atrial electrogram ablation was performed (single procedure: 9 patients, multiple procedures: 20 patients). RESULTS: The Kaplan-Meier estimate of the 1-year freedom from atrial tachyarrhythmias without antiarrhythmic drugs was 65% in all patients, (73%, 56%, and 11% in groups A, B, and C, respectively) after a single procedure, which improved to 86% in all patients (93%, 86%, and 53% in groups A, B, and C, respectively) after multiple procedures. CONCLUSION: Even for LSPAF, in approximately 60% of patients, non-PV triggers were not elicited, and PVI plus PWI alone achieved good outcomes. Although the inducibility of non-PV triggers was associated with recurrence of atrial tachyarrhythmias, additional non-PV trigger ablation may improve the outcome after multiple procedures.