Key result
Pulmonary vein isolation plus linear ablation did not significantly improve long-term freedom from atrial fibrillation compared to pulmonary vein isolation plus CFAE ablation (48.3% vs 44.6%, HR 1.34, p=0.412).
Why the study?
Due to high AF recurrence rates after PVI alone in persistent AF, the optimum complementary ablation strategy in addition to PVI is unknown.
Does pulmonary vein isolation plus linear ablation improve freedom from atrial fibrillation recurrence compared to pulmonary vein isolation plus CFAE ablation in patients with persistent atrial fibrillation?
RCT (n=92)
Open-label
1:1
No
Does pulmonary vein isolation plus linear ablation improve freedom from atrial fibrillation recurrence compared to pulmonary vein isolation plus CFAE ablation in patients with persistent atrial fibrillation?
In patients with persistent atrial fibrillation, adding either linear ablation or CFAE ablation to pulmonary vein isolation results in similar, modest long-term freedom from atrial fibrillation.
Answers are grounded in this paper and cite their sources.
Neither strategy superior; confirms equivalent modest long-term efficacy of linear versus CFAE ablation added to PVI.
BACKGROUND: Pulmonary vein isolation remains the cornerstone of atrial fibrillation (AF) ablation. However, due to high recurrence rates, especially in patients with persistent AF, PV antral isolation, complemented by linear ablation, autonomic modulation, and ablation of complex fractionated electrograms, have been attempted to increase the odds of success. However, the optimum approach for a complementary strategy in addition to PVI for persistent AF is unknown. METHODS: We performed a prospective randomized trial by assigning 92 patients with persistent AF in 1:1 ratio to pulmonary-vein isolation plus ablation of electrograms showing complex fractionated activity (45 patients), or pulmonary-vein isolation plus additional linear ablation across the left atrial roof and mitral valve isthmus (47 patients). The duration of follow-up was five years. The primary endpoint was freedom from any documented recurrence of atrial fibrillation after a single ablation procedure. RESULTS: At a 12-month follow-up, 9 (23%) patients had AF recurrence in the linear ablation and 8 (21%) patients in the CFAE groups. At a mean follow-up duration of 59±36 months, 48.3% of patients in the linear ablation group and 44.6% of patients in the CFAE group were free from AF (p=0.403). There were no significant differences between the two groups for independent predictors of freedom from AF. The overall procedure time and radiation exposure were higher in the PVI+linear ablation group. There were five adverse events noted, two in the linear group (pericardial effusion not requiring drain) and 3 in the CFAE group (1 pseudoaneurysm, one effusion requiring pericardiocentesis and one effusion nor requiring drain). CONCLUSIONS: Among patients with persistent atrial fibrillation, we found no difference in maintenance of sinus rhythm in either linear ablation or ablation of complex fractionated electrograms was performed in addition to pulmonary vein isolation in short- and long-term follow-up.
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A 2020 study conducted an RCT in Persistent Atrial Fibrillation (n=92). Pulmonary vein isolation plus linear ablation vs. Pulmonary vein isolation plus complex fractionated atrial electrograms (CFAE) ablation was evaluated on Freedom from any documented recurrence of atrial fibrillation after a single ablation procedure (HR 1.34, 95% CI 0.666-2.695, p=0.412). Pulmonary vein isolation plus linear ablation did not significantly improve long-term freedom from atrial fibrillation compared to pulmonary vein isolation plus CFAE ablation (48.3% vs 44.6%, HR 1.34, p=0.412).
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