Clinical outcomes following protocol-mandated redo ablation in advanced persistent atrial fibrillation

BACKGROUND: Patients with persistent atrial fibrillation (AF) associated with scarred/low voltage left atrial myocardium have suboptimal outcomes following pulmonary vein isolation (PVI). In the LAUDABLE study, we showed that PVI durability in these patients is poor. Here, we report follow-up outcomes from LAUDABLE, including relevance of posterior wall isolation (PWI), quality of life (QOL) and cardiac dysfunction as measured by N-terminal pro-B-type natriuretic peptide (NT-proBNP). METHODS: LAUDABLE was a single-centre, pilot randomised controlled study. Patients with persistent AF were randomised to cryoballoon (CB) PVI or contact force and local impedance guided radiofrequency (RF) PVI. Patients underwent a protocol mandated 2-month redo procedure to isolate reconnected PVs. The index RF group additionally underwent PWI during the redo procedure. Arrhythmia follow-up included daily handheld ECGs, clinical review, QOL questionnaires and NT-proBNP analysis at 12 months. RESULTS: 38 patients underwent both procedures (17 CB/PVI-only, 21 RF/PVI+PWI). Over median 303 day follow-up, arrhythmia-free survival was observed in 23 (61%) patients, similar between arms (Kaplan-Meier estimate: CB/PVI-only 58.8% [95% CI 38.8-87.5%] vs RF/PVI+PWI 61.9% [95% CI 44.3-86.6%]; p=0.788). Significant improvements in QOL (AFEQT baseline: 61 vs follow-up: 96; p<0.001) and NT-proBNP (baseline: 535pg/mL vs follow-up: 151pg/mL; p=0.004) were observed. CONCLUSION: The majority of patients with significant left atrial scar at index ablation, who may be considered unsuitable for redo, derived significant benefit following durable PVI in terms of arrhythmia burden, QOL and NT-proBNP. Accepting low patient numbers, PWI offered no additive benefits.