P1420Selecting persistent atrial fibrillation patients for pulmonary vein isolation based on the response to amiodarone: efficacy of the one-step-back strategy

Introduction: Pulmonary vein isolation (PVI) by catheter ablation has reduced efficacy for the treatment of persistent atrial fibrillation (persAF), as compared to paroxysmal atrial fibrillation (paroxAF), likely due to adverse remodeling of the atria. Atrial remodeling can be reversed when sinus rhythm (SR) is restored for prolonged periods and when successful this predicts a better outcome of PVI. We hypothesized that when pretreatment of persAF patients with amiodarone results in a "step back" to the paroxysmal stage, the efficacy of PVI would be comparable to that of patients with paroxAF. Methods: Sixty two consecutive persAF patients and 62 paroxAF patients matched in age, gender, AF history and concomitant diseases were included. Persistent patients were started on amiodarone and cardioverted to SR. PVI was performed after three months in those who "stepped back" and had sustained SR and in all paroxAF patients. Amiodarone was stopped two months after PVI. Results: Five of the 62 (8%) patients returned to persAF after cardioversion despite amiodarone. The remaining 119 patients underwent PVI and were followed for a mean of 31 ± 14 months. Redo procedures were performed in 44 % and 27 % in the persAF and paroxAF group (p=0.06), respectively. The recurrence rate after multiple procedures without antiarrhythmic drugs was similar among the persAF and paroxAF patients (11% and 5%) at 6 months (p=0.21), but increased in the persAF group at one year (21% and 5%, p=0.01) and exceeded that of the paroxAF group at the end of the follow up (26% and 10%, p=0.02). Kaplan-Meier survival analysis showed shorter time to recurrence in the persAF group (p=0.01). Conclusion: PersAF patients who "step back" to the paroxysmal stage on amiodarone enjoy similar short term success after PVI, however late recurrences are more common compared to paroxAF.