Five-Year Follow-Up After Catheter Ablation of Persistent Atrial Fibrillation Using the Stepwise Approach and Prognostic Factors for Success

Schreiber, Doreen; Rostock, Thomas; Fröhlich, Max; Sultan, Arian; Servatius, Helge; Hoffmann, Boris; Lüker, Jakob; Berner, Imke; Schäffer, Benjamin; Wegscheider, Karl; Lezius, Susanne; Willems, Stephan; Steven, Daniel

doi:10.1161/circep.114.001672

Cited by 151 publications

(112 citation statements)

References 47 publications

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“…U takich pacjentów ablacja przezcewnikowa jest bardziej skuteczna niż farmakoterapia antyarytmiczna [185,586,713,[717][718][719][720]. W randomizowanych próbach klinicznych, w których oceniano ablację jako leczenie pierwszego rzutu u pacjentów z napadowym AF, wykazano jedynie nieco lepsze wyniki pod względem utrzymywania rytmu zatokowego w porównaniu z farmakoterapią antyarytmiczną [585,[721][722][723].…”

Section: Wskazaniaunclassified

“…Początkowo PVI zbadano u pacjentów z napadowym AF, ale wydaje się, że również w przetrwałym AF jest to metoda nie gorsza niż bardziej rozległa ablacja [729,735]. U pacjentów z przetrwałym AF wykonywano także bardziej rozległe zabiegi ablacji, ale nie ma wystarczających danych, by obecnie sformułować zalecenia dotyczące ich wykonywania [117,718,719,[735][736][737]. Rozległe zabiegi ablacji (wykraczające poza PVI) zawsze wymagają dłuższego czasu trwania zabiegu i większej ekspozycji na promieniowanie jonizujące, co potencjalnie stwarza zagrożenie dla pacjentów.…”

Section: Metody I Technologieunclassified

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2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS

Kirchhof

Benussi

Kotecha³

et al. 2016

Kardiol Pol

2,379

4,206

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Section: Wskazaniaunclassified

Section: Metody I Technologieunclassified

2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS

Kirchhof

Benussi

Kotecha³

et al. 2016

Kardiol Pol

2,379

4,206

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“…In contrast, 2 large registries reported single-procedure success rates of only 35.3% and 47.8% at 12 months. 16,17 The recently published single-center randomized CHASE-AF trial (Randomized Catheter Ablation of Persistent Atrial Fibrillation Study) investigated the stepwise approach (termed full defragmentation) versus standalone PVI in patients with persistent AF. The trial could not demonstrate a difference in arrhythmia recurrence during 12 months of follow-up; a higher incidence of AT as the mode of recurrence was observed in the full defragmentation group.…”

Section: Current Ablation Strategies For Chronic Afmentioning

confidence: 99%

“…Several single-arm registries reported that conversion of AF (to SR or AT) during ablation impacted positively on longterm clinical success, 16,17,[20][21][22] whereas others, including the randomized CHASE-AF trial, did not demonstrate a beneficial impact of AF conversion. 11,15 In our analysis, conversion of AF was not associated with a superior clinical outcome.…”

Section: Conversion Of Af and Arrhythmia Recurrencementioning

confidence: 99%

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

Fink

Schlüter

Heeger

et al. 2017

Circ: Arrhythmia and Electrophysiology

145

105

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C atheter ablation has become a routine treatment option for patients experiencing symptomatic paroxysmal atrial fibrillation (AF). Long-term clinical success rates of ≤80% after 5 years have been reported for the treatment of paroxysmal AF by initial stand-alone pulmonary vein isolation (PVI) as the accepted cornerstone of all AF ablation strategies; however, to achieve permanent PVI, multiple procedures are often required. 1,2 In contrast, the results for ablation of persistent AF are less convincing. 3 The optimal strategy for persistent AF is not known, and previous studies investigating more extensive ablation strategies in addition to PVI demonstrated heterogeneous results. [4][5][6][7][8][9][10][11][12] The recently published STAR AF 2 trial (Substrate and Trigger Ablation for Reduction of Atrial Fibrillation Trial) compared initial stand-alone PVI to PVI with additional ablation of complex fractionated atrial electrograms (CFAEs) or additional linear ablation and could not demonstrate a superior outcome for the additional ablation strategies. 13 The prospective and randomized Alster-Lost-AF © 2017 American Heart Association, Inc. Original ArticleBackground-Pulmonary vein isolation (PVI) for persistent atrial fibrillation is associated with limited success rates and often requires multiple procedures to maintain stable sinus rhythm. In the prospective and randomized Alster-Lost-AF trial (Ablation at St. Georg Hospital for Long-Standing Persistent Atrial Fibrillation), we sought to assess, in patients with symptomatic persistent or long-standing persistent atrial fibrillation, the outcomes of initial ablative strategies comprising either stand-alone PVI (PVI-only approach) or a stepwise approach of PVI followed by complex fractionated atrial electrogram ablation and linear ablation (Substrate-modification approach). Methods and Results-Patients were randomized 1:1 to stand-alone PVI or PVI plus substrate modification. The primary study end point was freedom from recurrence of any atrial tachyarrhythmia, outside a 90-day blanking period, at 12 months. A total of 124 patients were enrolled, with 118 patients included in the analysis (61 in the PVI-only group, 57 in the Substrate-modification group). Atrial tachyarrhythmias recurred in 28 PVI-only group patients and 24 Substratemodification group patients, for 1-year freedom from tachyarrhythmia recurrence after a single ablation procedure of 54% (95% confidence interval, 43%-68%) in the PVI-only and 57% (95% confidence interval, 46%-72%) in the Substratemodification group (P=0.86). Twenty-four patients in the PVI-only group (39%) and 18 in the Substrate-modification group (32%) were without arrhythmia recurrence and off antiarrhythmic drug therapy at the end of the 12-month follow-up. Conclusions-In

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“…1 While the cornerstone of CA of paroxysmal AF is pulmonary vein (PV) isolation, catheter-based treatment of persistent and long-standing persistent arrhythmia varies across centers and among electrophysiologists. Different schools of thought have proposed and tested various approaches: staged approach, 2 linear ablation lines, 3 ablations of fractionated potentials, 4 ganglionic plexi ablation, 5 elimination of low-voltage areas in the left atrium (LA), 6 ablation of focal impulses and rotors, 7 or different combinations, which were driven mainly by unsatisfactory results reported for ablations, in general. The multicenter randomized STAR-AF II trial (The Substrate and Trigger Ablation for Reduction of Atrial Fibrillation Trial Part II) found no reduction in the rate of AF recurrence when PV isolation, in patients with persistent AF, was supplemented with linear ablations or ablations of complex fractionated electrograms.…”

mentioning

confidence: 99%

Correlates of Arrhythmia Recurrence After Hybrid Epi- and Endocardial Radiofrequency Ablation for Persistent Atrial Fibrillation

Bulava

Mokráček

Haniš

et al. 2017

Circ: Arrhythmia and Electrophysiology

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Background-Long-term efficacy of catheter-based treatment of persistent atrial fibrillation is unsatisfactory. Minimally invasive surgical ablation techniques have been developed recently, but their efficacy has never been systematically tested. Methods and Results-Seventy patients (median age, 63.5 years) with persistent atrial fibrillation underwent epicardial thoracoscopic radiofrequency pulmonary vein isolation, linear ablation, Marshal ligament disruption, and exclusion of the left atrial appendage. The procedure was followed by electroanatomic mapping and ablation (EAM) 2 to 3 months later. Only 76% of patients were in normal sinus rhythm at the beginning of EAM. All 4 pulmonary veins and the left atrium posterior wall were found isolated in 69% and 23% of patients, respectively. Arrhythmia-free survival off antiarrhythmic drugs 12 months after EAM was 77%. Using previously ineffective antiarrhythmic drugs and reablation procedures, arrhythmia free-survival increased to 97% during follow-up (mean, 936±432 days; range, 346-1509 days). The majority of arrhythmia recurrences occurred during the first 12 months after EAM. In a multivariable-adjusted estimates, left atrium volume >165 mL, absent normal sinus rhythm at admission for EAM, and inducibility of any sustained tachyarrhythmia at the end of EAM procedure were identified as independent correlates of atrial fibrillation recurrence. Conclusions-Our report demonstrated that the majority of patients after epicardial ablation, using bipolar radiofrequency instruments, required endocardial catheter ablation to complete the linear ablation lesions and a significant proportion of patients required spot-ablations to complete electric pulmonary vein isolation. Noninducibility of any arrhythmia after a staged hybrid procedure seemed to be the strongest correlate of long-term arrhythmia-free survival.

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Five-Year Follow-Up After Catheter Ablation of Persistent Atrial Fibrillation Using the Stepwise Approach and Prognostic Factors for Success

Cited by 151 publications

References 47 publications

2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS

2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS

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

Correlates of Arrhythmia Recurrence After Hybrid Epi- and Endocardial Radiofrequency Ablation for Persistent Atrial Fibrillation

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