Key result
Posterior wall debulking linked to ~46% lower AF recurrence versus PVI alone in persistent AF.
Why the study?
Although pulmonary vein isolation is the cornerstone of ablation therapy, the role of additional left atrial substrate modification in persistent AF remains controversial.
Does pulmonary vein isolation combined with posterior wall debulking improve arrhythmia-free survival compared to PVI alone or PVI with a posterior box lesion in patients with persistent AF?
Cohort (n=133)
Does pulmonary vein isolation combined with posterior wall debulking improve arrhythmia-free survival compared to PVI alone or PVI with a posterior box lesion in patients with persistent AF?
Answers are grounded in this paper and cite their sources.
Retrospective analysis assesses arrhythmia-free survival in persistent atrial fibrillation after various ablation techniques, implying potential for improved outcomes.
Background Catheter ablation is currently the most effective rhythm control strategy for atrial fibrillation (AF). Although pulmonary vein isolation (PVI) remains the cornerstone of ablation therapy, the role of additional left atrial substrate modification in patients with persistent AF remains controversial. Objective To assess the efficacy and safety of three radiofrequency (RF) ablation strategies—PVI alone, PVI with posterior box lesion (PostBOX), and PVI with posterior wall debulking (PWD)—in patients with persistent AF. Methods A retrospective analysis was conducted on 133 patients with persistent AF (66.9% male; mean age 62.4 ± 13.4 years; AF duration 6.0 ± 5.7 years) who underwent first-time RF catheter ablation. PVI group (n = 44): PVI alone using a high-power short-duration (HPSD, 50 W) technique. PostBOX group (n = 41): PVI combined with a posterior box lesion (HPSD, 50 W).PWD group (n = 48): PVI combined with posterior wall "debulking" (anterior wall ablation using HPSD, 50 W; posteriorwall ablation using very high-power short-duration [vHPSD], 90 W).The primary endpoint was AF recurrence after a 3-month blanking period, defined as any atrial tachyarrhythmia lasting >30 seconds or requiring cardioversion after a single procedure. Secondary endpoints included arrhythmia recurrence patterns, need for cardioversion, and procedural characteristics. Results All patients completed 12 months of follow-up (mean follow-up 12 ± 9 months). Sinus rhythm without antiarrhythmic drugs was maintained in: 50% of patients in the PVI group, 56% in the PostBOX group, and 73% in the PWD group (Chi-square test P < 0.04 as compared to PVI, and PWD). Major complication rates were low and comparable among groups (2.4% vs. 2.2% vs. 0%, respectively; P = 0.10). Procedure duration was significantly shorter in the PVI group [71 (58–78) min] compared with the PostBOX [88 (71–91) min, P = 0.01] and PWD [90 (77–97) min, P = 0.02] groups. Conclusion In patients with persistent AF, posterior wall debulking using very high-power short-duration ablation demonstrated superior arrhythmia-free survival compared with PVI or PWD plus , without an increase in procedural complications. These findings support further evaluation of atrial "debulking" as a substrate modification strategy in persistent AF.
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Kardos et al. (2026) conducted a cohort in persistent atrial fibrillation (n=133). Posterior wall debulking (PWD) vs. PVI alone or PVI with posterior box lesion (PostBOX) was evaluated on AF recurrence after a 3-month blanking period (reported as maintenance of sinus rhythm) (p=<0.04). Posterior wall debulking using very high-power short-duration ablation maintained sinus rhythm in 73% of patients with persistent AF compared to 50% with PVI alone (P<0.04).
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