Key result
PVI alone shows no significant difference in AF recurrence versus PVI plus extensive ablation.
Why the study?
The efficacy of pulmonary vein isolation alone versus extensive ablation for persistent atrial fibrillation with different trigger-based and substrate-based mechanisms was uncertain.
Does a PVI-alone strategy compared to a PVI-plus strategy prevent AF recurrence in patients with persistent atrial fibrillation with trigger-based vs. substrate-based mechanisms?
RCT (n=496)
Open-label
1:1
Yes
Does a PVI-alone strategy compared to a PVI-plus strategy prevent AF recurrence in patients with persistent atrial fibrillation with trigger-based vs. substrate-based mechanisms?
The relative efficacy of PVI alone compared to extensive ablation for persistent atrial fibrillation is consistent regardless of whether the underlying mechanism is trigger-based or substrate-based.
Answers are grounded in this paper and cite their sources.
Supports mechanism-agnostic ablation choice in persistent AF; confirms consistent relative efficacy of PVI strategies across mechanisms.
BACKGROUND: Extensive ablation in addition to pulmonary vein isolation (PVI) would be effective for modification of non-pulmonary vein (non-PV) substrates, whereas PVI might be sufficient for elimination of PV triggers. This study aimed to test the hypothesis that in patients with reproducible atrial fibrillation (AF) triggered by premature atrial contractions originating only from PVs, PVI alone can be sufficient to maintain sinus rhythm. METHODS AND RESULTS: This study is a prespecified subanalysis of the EARNEST-PVI randomized controlled trial. This study investigated the efficacy of the PVI-alone strategy (PVI-alone) in comparison with the extensive strategy (PVI-plus) for persistent AF with a trigger-based mechanism vs. a substrate-based mechanism. Patients were stratified into 3 groups based on AF mechanisms: (1) Substrate group (N=236); (2) PV trigger group (N=236); and (3) non-PV trigger group (N=24). The hazard ratios for AF recurrence of the PVI-alone strategy with reference to the PVI-plus strategy were 1.456 (95% confidence interval [CI] [0.864-2.452]) in the substrate group, 1.648 (95% CI 0.969-2.801) in the PV trigger group, and 0.937 (95% CI 0.252-3.488) in the non-PV trigger group. No significant interaction between ablation strategy and AF mechanism was observed (P for interaction=0.748). CONCLUSIONS: This study indicated that the efficacies of the PVI-alone strategy compared with the PVI-plus strategy were consistent across persistent AF with trigger-based and substrate-based mechanisms.
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A 2021 study conducted an RCT in Persistent atrial fibrillation (n=496). Pulmonary vein isolation (PVI) alone vs. PVI plus extensive ablation (CFAE and/or linear ablation) was evaluated on Recurrence of atrial fibrillation at 1 year (PV trigger group) (HR 1.648, 95% CI 0.969-2.801, p=0.062). Pulmonary vein isolation (PVI) alone yielded a numerically higher rate of atrial fibrillation recurrence compared to PVI plus extensive ablation in the PV trigger group (29.5% vs 19.3%, HR 1.648), with consistent relative efficacy across all AF mechanisms (P for interaction=0.748).
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