Key result
Incomplete linear lesion block during stepwise ablation independently predicted arrhythmia recurrence (HR 4.69; 95% CI 1.05-21.06; P=0.04).
Why the study?
Does stepwise ablation reduce the surface area of complex fractionated electrograms in patients with persistent atrial fibrillation and heart failure?
Cohort (n=30)
Does stepwise ablation reduce the surface area of complex fractionated electrograms in patients with persistent atrial fibrillation and heart failure?
Hazard Ratio: 4.69 (95% CI 1.05–21.06)
p-value: p=0.04
In patients with persistent AF and HFrEF, stepwise ablation progressively reduces the biatrial substrate area of complex fractionated electrograms, with complete linear lesions predicting better arrhythmia-free survival.
Incomplete linear block may raise recurrence risk after stepwise ablation in persistent AF with HFrEF; leaves open whether targeting complete lesions improves outcomes.
BACKGROUND: Ablation of persistent atrial fibrillation can be challenging, often involving not only pulmonary vein isolation (PVI) but also additional linear lesions and ablation of complex fractionated electrograms (CFE). We examined the impact of stepwise ablation on a human model of advanced atrial substrate of persistent atrial fibrillation in heart failure. METHODS AND RESULTS: In 30 patients with persistent atrial fibrillation and left ventricular ejection fraction ≤35%, high-density CFE maps were recorded biatrially at baseline, in the left atrium (LA) after PVI and linear lesions (roof and mitral isthmus), and biatrially after LA CFE ablation. Surface area of CFE (mean cycle length ≤120 ms) remote to PVI and linear lesions, defined as CFE area, was reduced after PVI (18.3±12.03 to 10.2±7.1 cm(2); P<0.001) and again after linear lesions (7.7±6.5 cm(2); P=0.006). Complete mitral isthmus block predicted greater CFE reduction (P=0.02). Right atrial CFE area was reduced by LA ablation, from 25.9±14.1 to 12.9±11.8 cm(2) (P<0.001). Estimated 1-year arrhythmia-free survival was 72% after a single procedure. Incomplete linear lesion block was an independent predictor of arrhythmia recurrence (hazard ratio, 4.69; 95% confidence interval, 1.05-21.06; P=0.04). CONCLUSIONS: Remote LA CFE area was progressively reduced following PVI and linear lesions, and LA ablation reduced right atrial CFE area. Reduction of CFE area at sites remote from ablation would suggest either regression of the advanced atrial substrate or that these CFE were functional phenomena. Nevertheless, in an advanced atrial fibrillation substrate, linear lesions after PVI diminished the target area for CFE ablation, and complete lesions resulted in a favorable clinical outcome.
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Jones et al. (2013) conducted a cohort in persistent atrial fibrillation and heart failure (n=30). Incomplete linear lesion block during stepwise ablation vs. Complete linear lesion block was evaluated on Arrhythmia recurrence (HR 4.69, 95% CI 1.05-21.06, p=0.04). Incomplete linear lesion block during stepwise ablation independently predicted arrhythmia recurrence (HR 4.69; 95% CI 1.05-21.06; P=0.04).
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