Does additional linear ablation after circumferential pulmonary vein isolation improve clinical outcome in patients with paroxysmal atrial fibrillation? Prospective randomised study

Abstract

ObjectiveCircumferential pulmonary vein isolation (CPVI) has been considered the cornerstone of radiofrequency catheter ablation (RFCA) for atrial fibrillation (AF). However, it is unclear whether linear ablation in addition to CPVI improves clinical outcome.DesignProspective randomised study to compare the efficacy of CPVI and CPVI with additional linear ablation in patients with paroxysmal AF (PAF).SettingUniversity hospital.PatientsThis study enrolled 156 patients (male 76.3%, 55.8±11.5 years old (mean±SD)) who underwent RFCA for PAF.InterventionsCPVI (n=52), CPVI+roof line (CPVI+RL; n=52) and CPVI+RL+posterior inferior line (CPVI+PostBox; n=52).Main outcome measuresProcedure time, ablation time and clinical outcome.Results(1) The CPVI group showed shorter total procedure time (180.4±39.5 min vs 189.6±29.0 min and 201.7±51.7 min, respectively (mean±SD); p=0.035) and ablation time (4085.5±1384.1 s vs 5253.5±1010.9 s and 5495.0±1316.0 s, respectively; p<0.001) than the CPVI+RL and CPVI+PostBox groups. (2) During 15.6±5.0 months of follow-up, the recurrence rates 3 months after RFCA were 11.5% in CPVI, 21.2% in CPVI+RL and 19.2% in CPVI+PostBox (p=0.440). (3) The achievement rate of CPVI was 100.0%, and bidirectional block rate was 80.8% in CPVI+RL and 59.6% in CPVI+PostBox. The clinical recurrence rates with or without achieving bidirectional block were not significantly different from each other (p=0.386).ConclusionIn patients with PAF, linear ablation in addition to CPVI did not improve clinical outcome, regardless of bidirectional block achievement, while it prolonged the total procedure and ablation time.

Benefit of Left Atrial Roof Linear Ablation in Paroxysmal Atrial Fibrillation: A Prospective, Randomized Study

“…To our knowledge, only 2 other randomized studies have evaluated the effect of linear ablation at the LA roof, with conflicting results . Hocini et al .…”

Catheter Ablation of Lone Atrial Fibrillation

“…However, circumferential antral PV isolation, particularly if it is combined with additional modification of AF substrate, whether by the linear LA ablation and/or CFAE ablation, may lead to the occurrence of atrial tachycardia in 7.6%-44% of patients [24,42,54,[194][195][196]. After usage of similar ablative strategy (CFAE + PVI), post-procedural incidence of atrial tachycardia was remarkably higher after the ablation of persistent AF than after the ablation of paroxysmal AF (20.0% vs. 2.4%) [197].…”

“…There are three basic strategies for modification of AF substrate: LA defragmentation by ablation of the complex fragmented atrial electrograms (CFAE), linear ablation of LA and ganglionated plexi ablation [3,[21][22][23][24][25][26][27][28][29]. CFAE are the electrograms during AF which have short cycle length (<120ms) or which are fractionated into two or more components, or show continuous atrial electrical activation [50].…”

Almanac 2013: cardiac arrhythmias and pacing

“…Late recurrences (defined as 6–12 months following the initial AF ablation procedure) was associated with PV reconnection in all patients, while very late recurrences (>12 months after the procedure) were associated with non-PV triggers in 85.7% of cases. The added benefit of performing additional linear ablation lines after PV isolation on improving outcomes following AF ablation has been further questioned in a prospective, randomised study of 156 patients with paroxysmal AF who were randomly assigned to undergo PV isolation only, PV isolation and a roof line, or PV isolation, roof line and a posterior inferior line 35. The investigators found no improvement in clinical outcome in the patients who received the additional lines while, unsurprisingly, the addition of the linear ablations significantly prolonged procedure times.…”