ImportancePulmonary vein isolation (PVI) alone is less effective in patients with persistent atrial fibrillation (AF) compared with paroxysmal AF. The left atrial posterior wall may contribute to maintenance of persistent AF, and posterior wall isolation (PWI) is a common PVI adjunct. However, PWI has not been subjected to randomized comparison.ObjectiveTo compare PVI with PWI vs PVI alone in patients with persistent AF undergoing first-time catheter ablation.Design, Setting, and ParticipantsInvestigator initiated, multicenter, randomized clinical trial involving 11 centers in 3 countries (Australia, Canada, UK). Symptomatic patients with persistent AF were randomized 1:1 to either PVI with PWI or PVI alone. Patients were enrolled July 2018-March 2021, with 1-year follow-up completed March 2022.InterventionsThe PVI with PWI group (n = 170) underwent wide antral pulmonary vein isolation followed by posterior wall isolation involving linear ablation at the roof and floor to achieve electrical isolation. The PVI-alone group (n = 168) underwent wide antral pulmonary vein isolation alone.Main Outcomes and MeasuresPrimary end point was freedom from any documented atrial arrhythmia of more than 30 seconds without antiarrhythmic medication at 12 months, after a single ablation procedure. The 23 secondary outcomes included freedom from atrial arrhythmia with/without antiarrhythmic medication after multiple procedures, freedom from symptomatic AF with/without antiarrhythmic medication after multiple procedures, AF burden between study groups at 12 months, procedural outcomes, and complications.ResultsAmong 338 patients randomized (median age, 65.6 [IQR, 13.1] years; 76.9% men), 330 (97.6%) completed the study. After 12 months, 89 patients (52.4%) assigned to PVI with PWI were free from recurrent atrial arrhythmia without antiarrhythmic medication after a single procedure, compared with 90 (53.6%) assigned to PVI alone (between-group difference, –1.2%; hazard ratio [HR], 0.99 [95% CI, 0.73-1.36]; P = .98). Of the secondary end points, 9 showed no significant difference, including freedom from atrial arrhythmia with/without antiarrhythmic medication after multiple procedures (58.2% for PVI with PWI vs 60.1% for PVI alone; HR, 1.10 [95% CI, 0.79-1.55]; P = .57), freedom from symptomatic AF with/without antiarrhythmic medication after multiple procedures (68.2% vs 72%; HR, 1.20 [95% CI, 0.80-1.78]; P = .36) or AF burden (0% [IQR, 0%-2.3%] vs 0% [IQR, 0%-2.8%], P = .47). Mean procedural times (142 [SD, 69] vs 121 [SD, 57] minutes, P < .001) and ablation times (34 [SD, 21] vs 28 [SD, 12] minutes, P < .001) were significantly shorter for PVI alone. There were 6 complications for PVI with PWI and 4 for PVI alone.Conclusions and RelevanceIn patients undergoing first-time catheter ablation for persistent AF, the addition of PWI to PVI alone did not significantly improve freedom from atrial arrhythmia at 12 months compared with PVI alone. These findings do not support the empirical inclusion of PWI for ablation of persistent AF.Trial Registrationanzctr.org.au Identifier: ACTRN12616001436460

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JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact support@jstor.org.. Annals of Mathematics is collaborating with JSTOR to digitize, preserve and extend access to Annals of Mathematics.

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JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact support@jstor.org.. Biometrika Trust is collaborating with JSTOR to digitize, preserve and extend access to Biometrika. SUMMARY Methods for generalized linear models are extended to provide estimates of location and variance parameters for mixed models fitted to binomial data formed by classifying samples from an underlying normal distribution. The method estimates the parameters directly on the underlying scale. For a balanced one-way random effects model, the variance estimator simplifies to the usual analysis of variance one. The estimation of variances and the prediction of random effects for binomial traits is required by animal breeders. The predictors given are analogous to best linear unbiased predictors (Henderson, 1973) but differ from those presented by Harville & Mee (1984).

Idiopathic ventricular arrhythmias commonly originate from the right ventricular and left ventricular outflow tracts (OTs). Advances in real-time imaging have refined our understanding of the intimate anatomic structures implicated in the genesis of OT arrhythmias, making catheter ablation for arrhythmias beyond the right ventricular OT a feasible option for cure—indeed ablation is now a class I indication in recent guidelines. The surface 12-lead ECG is routinely used to localize the anatomic site of origin before catheter ablation. However, the intimate and complex anatomy of the OT limits predictive value ECG criteria alone for localization for these arrhythmias. Multiple ECG algorithms have been developed to assist preprocedural localization, and hence predict safety and efficacy for catheter ablation of OT ventricular arrhythmias. This review will summarize all of the published 12-lead ECG algorithms used to guide localization of OT ventricular arrhythmias.

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