Catheter Ablation of Long‐Lasting Persistent Atrial Fibrillation: Clinical Outcome and Mechanisms of Subsequent Arrhythmias

Abstract

Catheter ablation of long-lasting persistent AF associated with acute AF termination achieves medium to long-term restoration and maintenance of sinus rhythm in 95% of patients. Arrhythmia recurrence in the majority of patients is AT.

Stand-Alone Pulmonary Vein Isolation Versus Pulmonary Vein Isolation With Additional Substrate Modification as Index Ablation Procedures in Patients With Persistent and Long-Standing Persistent Atrial Fibrillation

“…11,15 In our analysis, conversion of AF was not associated with a superior clinical outcome. Of note, we observed only a modest rate (about 60%) of patients in whom AF terminated during ablation, 11 although most of the studies which document a positive influence of AF termination had a higher conversion rate (66%-84%).…”

“…The difference in the type of atrial arrhythmia recurrence after stand-alone PVI versus PVI plus substrate modification is explained by the different ablation techniques. It was well described in the original article by Haïssaguerre et al 15 introducing the stepwise approach that AT was the dominant arrhythmia during follow-up, occurring in 23 of 52 patients, with AF recurring in only 2 patients. This finding was confirmed in a more recent article by the same group, 16 with 72.7% of 150 patients requiring repeat procedures (36.5% for AF and 63.5% for AT).…”

“…6,7,12 Nonetheless, results of other trials did not show a clinical benefit of additional CFAE ablation, 4,9 and the recently published STAR AF II trial revealed no difference in clinical outcomes when comparing stand-alone PVI to PVI plus additional CFAE or linear ablation in a large cohort of patients with persistent AF. 13 The stepwise ablation approach was first investigated by Haïssaguerre et al 15 and consisted of the sequential combination of PVI and additional ablation of CFAEs and, in case of conversion to AT during the ablation procedure, linear ablation; in that original study, 95% of patients were in SR after 1 year and multiple ablation procedures. In contrast, 2 large registries reported single-procedure success rates of only 35.3% and 47.8% at 12 months.…”

2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: Recommendations for Patient Selection, Procedural Techniques, Patient Management and Follow-up, Definitions, Endpoints, and Research Trial Design

“…514,515 The strategy starts by pulmonary isolation, followed by ablation of CFAE, looking for reversion to sinus rhythm or AT. If this endpoint is not achieved, additional linear lesions are deployed.…”

Contemporary Management of Atrial Fibrillation: Update on Anticoagulation and Invasive Management Strategies

“…Several studies have reported these lower success rates even with more aggressive ablation paradigms. [167][168][169] Recently, the use of extensive linear ablation aimed at organizing and subsequently eliminating chronic AF achieved slightly better results but with a limited follow-up period 168,169 ( Figure 9). …”