Evaluation of Linear Lesions in the Left and Right Atrium in Ablation of Long‐standing Atrial Fibrillation

BACKGROUND: This randomized prospective study compared three ablation strategies in patients with long-standing persistent atrial fibrillation (LPeAF). It also explored the best procedural endpoint from among the following: circumferential pulmonary vein isolation (PVI) + left atrial (LA) linear lesions (roofline, mitral isthmus) + complex fractionated atrial electrogram (CFAE) ablation, PVI + LA linear lesions + cavotricuspid isthmus (CTI) ablation + CFAE ablation, and PVI + CFAE ablation. METHODS AND RESULTS: A total of 210 patients with LPeAF referred for catheter ablation were enrolled and randomized into three ablation groups. The patients in group A (n = 70) underwent PVI followed by LA linear and CFAE ablation; in 93% of patients the primary endpoint was achieved (five patients with incomplete linear lesions). Of the 70 patients in group B who were subjected to PVI followed by LA linear, CFAE, and CTI ablations, in 94% of patients the primary endpoint was achieved (four patients with incomplete linear lesions). All patients in group C (n = 70) successfully underwent PVI and CFAE ablation. Direct current cardioversion was performed upon PVI, CFAE elimination, and completion of linear lesions. Patients were followed-up for atrial tachyarrhythmia recurrence for at least 24 months. After a single ablation procedure, group C (36%) exhibited the lowest success compared with group A (54%) and group B (51%) (P = 0.06). At the mean follow-up of 32 ± 9 months after the final ablation procedure, 53 patients (76%) in group A, 53 (76%) in group B, and 41 (59%) in group C were in sinus rhythm without antiarrhythmic drugs (P = 0.03). CONCLUSIONS: In LPeAF, linear lesions in the LA help improve outcome of ablation, additional CTI ablation does not.