Ectopy-triggering ganglionated plexus ablation is feasible as a solo strategy for persistent and long-standing persistent atrial fibrillation treatment

BACKGROUND: The GANGLIA-AF trial showed that ectopy-triggering ganglionated plexus (ET-GP) ablation alone, without pulmonary vein isolation (PVI), can prevent paroxysmal atrial fibrillation (AF) with similar success rates to PVI alone. However, it is not known whether ET-GP mapping and ablation are feasible in persistent AF. OBJECTIVE: This study aimed to perform mapping and ablation of left atrial ET-GP in patients with persistent AF and assess 1-year freedom from ≥30-second AF/atrial tachycardia (AT). METHODS: Patients with persistent AF, undergoing ablation, were pretreated with amiodarone. Three-dimensional geometry (CARTO/Precision) was collected in sinus rhythm after cardioversion. ET-GPs were mapped by delivering endocardial high-frequency stimulation within the atrial refractory period and ablated until they became nonfunctional. If triggered AF became incessant, atrioventricular-dissociating GPs (AVD-GPs) were ablated. No PVI was performed. Patients were followed up for 1 year to assess the recurrence of AF/AT. RESULTS: Forty-nine patients completed GP ablation (64 ± 9 years; 76% male; left atrial diameter 46 ± 8 mm; AF duration 3.4 ± 2.5 years; continuous AF lasting ≥12 months 41%). High-frequency stimulation was performed at a mean of 110 ± 20 sites, identifying 15 ± 9 GPs/patient (ET-GP only 12/49 [25%]; combination 31/49 [63%]; AVD-GP only 6/49 [12%]). ET-GP only ablation (12 ± 8 ET-GP) had higher freedom from persistent AF recurrence (11/12 [92%]) than combination ET/AVD-GP ablation (17 ± 9 GP; 13/31 [42%]) or AVD-GP only ablation (4 ± 0 AVD-GP; 1/6 [17%]) (P = .005). One-year freedom from ≥30-second AF/AT was 16 of 49 (33%), and freedom from persistent AF was 25 of 49 (51%) for the whole cohort. CONCLUSION: ET-GP mapping and ablation, as a solo ablation strategy, are feasible in persistent AF and can prevent AF recurrence at 1 year.