Electrogram‐Guided Driver Ablation Versus Posterior Wall Isolation in Persistent AF: A Propensity‐Matched Study

BACKGROUND: The optimal adjunctive ablation strategy beyond pulmonary vein isolation (PVI) for persistent atrial fibrillation (PsAF) remains uncertain. This study compared the procedural characteristics, periprocedural safety, and 12-month rhythm outcomes of driver-guided ablation versus posterior wall isolation (PWI) in patients with PsAF. METHODS: This multicenter retrospective study included 303 consecutive patients with PsAF who underwent PVI plus driver-guided ablation (n = 201) or PVI plus PWI (n = 102). Propensity score matching using prespecified clinical, cardiac structural, and atrial substrate variables yielded 102 matched pairs. An exploratory subgroup analysis was conducted according to left atrial low-voltage area (LVA) burden. RESULTS: In the overall cohort, procedure time was shorter in the PWI group than in the driver group (154.56 ± 38.85 vs. 189.70 ± 39.45 min; p < 0.001). At 12 months, the driver group showed higher rates of freedom from atrial arrhythmias (75.1% vs. 63.7%; p = 0.038) and freedom from AF (80.1% vs. 67.6%; p = 0.017), and a lower proportion of persistent atrial arrhythmia among patients with recurrence (28.0% vs. 64.9%; p < 0.001). Periprocedural complications were comparable between groups. In the matched cohort, these findings remained materially unchanged. In patients with LVA burden ≥10%, driver ablation was associated with a higher rate of freedom from atrial arrhythmias than PWI (68.2% vs. 50.9%; p = 0.046), although no significant interaction was observed. CONCLUSION: In patients with PsAF, PWI was associated with greater procedural efficiency, whereas driver-guided ablation was associated with better 12-month rhythm outcomes. These observational findings should be considered hypothesis-generating and require prospective validation.