Randomized Ablation Strategies for the Treatment of Persistent Atrial Fibrillation

Abstract

Background-The single-procedure efficacy of pulmonary vein isolation (PVI) is less than optimal in patients with persistent atrial fibrillation (AF). Adjunctive techniques have been developed to enhance single-procedure efficacy in these patients. We conducted a study to compare 3 ablation strategies in patients with persistent AF. Methods and Results-Subjects were randomized as follows: arm 1, PVI ϩ ablation of non-PV triggers identified using a stimulation protocol (standard approach); arm 2, standard approach ϩ empirical ablation at common non-PV AF trigger sites (mitral annulus, fossa ovalis, eustachian ridge, crista terminalis, and superior vena cava); or arm 3, standard approach ϩ ablation of left atrial complex fractionated electrogram sites. Patients were seen at 6 weeks, 6 months, and 1 year; transtelephonic monitoring was performed at each visit. Antiarrhythmic drugs were discontinued at 3 to 6 months. The primary study end point was freedom from atrial arrhythmias off antiarrhythmic drugs at 1 year after a single-ablation procedure. A total of 156 patients (aged 59Ϯ9 years; 136 males; AF duration, 47Ϯ50 months) participated (arm 1, 55 patients; arm 2, 50 patients; arm 3, 51 patients). Procedural outcomes (procedure, fluoroscopy, and PVI times) were comparable between the 3 arms. More lesions were required to target non-PV trigger sites than a complex fractionated electrogram (33Ϯ9 versus 22Ϯ9; PϽ0.001). The primary end point was achieved in 71 patients and was worse in arm 3 (29%) compared with arm 1 (49%; Pϭ0.04) and arm 2 (58%; Pϭ0.004). Conclusions-These

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

“…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.…”

Pharmacological Tests in Atrial Fibrillation Ablation

“…This has been examined in the Randomized Ablation Strategies for the Treatment of Persistent Atrial Fibrillation (RASTA) study, which compares: circumferential PVI plus ablation of non-PV triggers; circumferential PVI plus ablation of non-PV triggers plus empirical ablation at common non-PV trigger sites; and circumferential PVI plus ablation of non-PV triggers plus CFAE ablation. 87 The freedom from atrial arrhythmias after a single ablation procedure was significantly worse with the addition of CFAE (29 %) when compared with PVI plus non-PV triggers alone (49 %, p<0.040) and PVI plus non-PV triggers plus empirical trigger-site ablation (58 %, p<0.004).…”

“…Most studies considered repetitive premature atrial contraction as the target for ablation. 9,33,[81][82][83][84][85][86][87] Several repetitive premature atrial contractions, however, will never induce AF. As such, an increased success rate has been achieved when targeting only the premature atrial contractions that induce AF.…”

“…34 These negative results could be explained by the amount of ablation that increases the iatrogenic arrhythmia rate. 87,[97][98][99] To reduce this arrhythmia rate, two recent randomised studies have investigated the effect of ibutilide and amiodarone with respect to PVI and CFAE ablation. Mohanty et al described a 112-patient population treated with amiodarone for persistent AF.…”

Ablation of Atrial Fibrillation

“…Mapping and ablating AF substrate is one of the most activated debated topics within the field of ablation today, and is motivated by the large number of patients in whom AF recurs after eliminating PV 6, 7, 10-13 or non-PV triggers 54 , by evidence [55][56][57][58] that conventional ablation may inadvertently target substrates 52,59 , and by the fact that we ablate substrates (not triggers) for other arrhythmias.…”