Stepwise ablation approach versus pulmonary vein isolation in patients with paroxysmal atrial fibrillation: Randomized controlled trial

Faustino, Massimiliano; Pizzi, Carmine; Agricola, Tullio; Xhyheri, Borejda; Costa, Grazia Maria; Flacco, Maria Elena; Capasso, Lorenzo; Cicolini, Giancarlo; Girolamo, Enrico Di; Leonzio, Luigi; Manzoli, Lamberto

doi:10.1016/j.hrthm.2015.06.009

Cited by 16 publications

(7 citation statements)

References 24 publications

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“…20,21,30,31 Among these common sites of non-PV triggers, the SVC accounted for 76% (28/37) of cases in our study, which was much higher than the range of 6% to 12% reported previously. 22,24,26 The higher incidence of SVC trigger observed in our study might be related to ethnic differences from previous non-Asian studies or our use of a broad definition of non-PV trigger. Consistent with the former possibility, a high incidence (60%) of SVC trigger was reported in a study on an Asian population.…”

Section: Prevalence Of Non-pv Triggersmentioning

confidence: 50%

“…16,[19][20][21][22][23][24][25][26][27][28] Noninducibility of AF achieved by additional ablation after PVI is associated with lower AF recurrence compared with PVI alone. 23,24,28 However, Leong-Sit 29 et al reported that noninducibility of any atrial tachyarrhythmia is not predictive of clinical recurrence at a 1-year follow-up. In our study, a non-PV AF trigger was a predictor for atrial tachyarrhythmia recurrence; however, the identification of a PV trigger or the achievement of noninducibility was not ( Figure 5).…”

Section: Need For An Additional Procedural End Point Beyond Pvimentioning

confidence: 99%

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Long-Term Clinical Comparison of Procedural End Points After Pulmonary Vein Isolation in Paroxysmal Atrial Fibrillation

Lee

Roh

Baek

et al. 2018

Circ: Arrhythmia and Electrophysiology

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BACKGROUND:Pulmonary vein isolation (PVI) is effective for maintenance of sinus rhythm in 50% to 75% of patients with paroxysmal atrial fibrillation, and it is not uncommon for patients to require additional ablation after PVI. We prospectively evaluated the relative effectiveness of 2 post-PVI ablation strategies in paroxysmal atrial fibrillation. METHODS AND RESULTS:A total of 500 patients (mean age, 55.7±11.0 years; 74.6% male) were randomly assigned to undergo ablation by 2 different strategies after PVI: (1) elimination of non-PV triggers (group A, n=250) or (2) stepwise substrate modification including complex fractionated atrial electrogram or linear ablation until noninducibility of atrial tachyarrhythmia was achieved (group B, n=250). During a median follow-up of 26.0 months, 75 (32.2%) patients experienced at least 1 episode of recurrent atrial tachyarrhythmia after the single procedure in group A compared with 105 (43.8%) patients in group B (P value in log-rank test of Kaplan-Meier analysis: 0.012). Competing risk analysis showed that the cumulative incidence of atrial tachycardia was significantly higher in group B compared with group A (P=0.007). With the exception of total ablation time, there were no significant differences in fluoroscopic time or procedure-related complications between the 2 groups.CONCLUSIONS: Elimination of triggers as an end point of ablation in patients with paroxysmal atrial fibrillation decreased long-term recurrence of atrial tachyarrhythmia compared with a noninducibility approach achieved by additional empirical ablation. The post-PVI trigger test is thus a better end point of ablation for paroxysmal atrial fibrillation.

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Section: Prevalence Of Non-pv Triggersmentioning

confidence: 50%

Section: Need For An Additional Procedural End Point Beyond Pvimentioning

confidence: 99%

Long-Term Clinical Comparison of Procedural End Points After Pulmonary Vein Isolation in Paroxysmal Atrial Fibrillation

Lee

Roh

Baek

et al. 2018

Circ: Arrhythmia and Electrophysiology

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“…CFAEs were described by K. Nademanee, et al in 2004 and several previous studies showed that substrate modification targeted to CFAEs improved arrhythmia-free rate after catheter ablation procedure [15,18,19] . Conversely, broad ablation of all CFAEs could result in greater tissue destruction during catheter ablation for persistent AF and induce complex ATs after procedure [8,20,21] .STAR AF II trial, a recent randomized trial comparing three approaches to substrate ablation for persistent AF, showed no efficacy of CFAE and left atrial linear ablations [9] .Y.…”

Section: Discussionmentioning

confidence: 99%

Clinical Utility of Intravenous Nifekalant Injection during Radiofrequency catheter Ablation for Persistent Atrial Fibrillation

Kawaji

Shizuta

Yamagami

et al. 2018

Journal of Atrial Fibrillation

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Background: Radiofrequency catheter ablation (RFCA) for persistent atrial fibrillation (AF) is still challenging even in RFCA-era for AF. The aim of this study was to assess the clinical utility of nifekalant, a pure potassium channel blocker,during RFCA for persistent AF. Methods and Results: We retrospectively enrolled 157 consecutive persistent AF patients undergoing first RFCA procedure with complex fractionated atrial electrogram (CFAE) ablation after pulmonary veins isolation and compared outcomes between patients with (NFK group: N=79) and without (No-NFK group: N=78) additional CFAE ablation using intravenous nifekalant (0.3mg/kg). Primary endpoint was 24-month atrial arrhythmia-free survival post ablation.The prevalence of AF termination was significantly higher in NFK group than No-NFK group (64.6% versus 7.7%, P<0.001). Arrhythmia-free survival, however, was not significantly different between 2 groups (61.5% versus 54.1%, P=0.63).There was no significant difference between 2 groups in the prevalence of recurrent atrial tachycardia (25.0% versus 23.5%, P=0.89). Arrhythmia-free survivalin patients with AF termination during procedure was significantly higher than those without (73.0% versus 41.0%, P=0.002; adjusted hazard ratio 0.48, 95% confidence interval 0.17-0.84, P=0.02) among NFK group,but not among No-NFK group (66.7% versus 53.2%, P=0.53). Conclusions: Intravenous nifekalant injection during additional CFAE ablation did not improve sinus maintenance rate after RFCA procedure for AF, but AF termination by nifekalant injection could be a clinical predictor of better success rates after procedure.

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“…Routine linear, complex fractionated electrograms, and rotor ablations were reported associated with improved clinical outcomes compared with PVI alone ( 6 , 7 , 9 , 19 ). Faustino et al reported a stepwise ablation strategy that accomplished a 90.7% success rate after 12-month follow-up in PAF patients ( 20 ). However, in a more recent study, elimination of triggers as an end point of ablation in patients with PAF showed a lower recurrence compared with stepwise substrate modifications ( 21 ).…”

Section: Resultsmentioning

confidence: 99%

Prevalence and Predictors of Additional Ablation Beyond Pulmonary Vein Isolation in Patients With Paroxysmal Atrial Fibrillation

Xie

Yang

et al. 2021

Front. Cardiovasc. Med.

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Background: Pulmonary vein isolation (PVI) is an effective strategy in the treatment of paroxysmal atrial fibrillation (PAF). Yet, there are limited data on additional ablation beyond PVI. In this study, we sought to assess the prevalence, predictors, and outcomes of additional ablation in PAF patients.Methods: A total of 537 consecutive patients with PAF were retrospectively evaluated for the index procedure. PVI was successfully conducted in all patients, after which electrophysiological study and drug provocation were performed, and additional ablations were delivered for concomitant arrhythmias, non-PV triggers, and low voltage zone (LVZ). The prevalence, predictors, and outcomes of additional ablation were analyzed.Results: Among 537 consecutive patients, 372 addition ablations were performed in 241 (44.88%) patients, including 252 (67.74%) concomitant arrhythmias in 198 (36.87%) patients, 56 (15.05%) non-PV triggers in 52 (9.68%) patients and 64 (17.20%) LVZ modification in 47 (8.75%) patients. Lower LVEF (OR = 0.937, p = 0.015), AF episode before procedure (OR = 2.990, p = 0.001), AF episode during procedure (OR = 1.998, p = 0.002) and AF episode induced after PVI (OR = 15.958, p < 0.001) were independent predictors of additional ablation. Single-procedure free from atrial arrhythmias at 58.36 ± 7.12 months post-ablation was 70.48%.Conclusions: Additional ablations were common in patients with PAF for index procedure. Lower LVEF and AF episodes before, during the procedure, and induced after PVI predicts additional ablation.

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Stepwise ablation approach versus pulmonary vein isolation in patients with paroxysmal atrial fibrillation: Randomized controlled trial

Abstract: In addition to PVI, stepwise ablation achieving sinus rhythm and nonatrial arrhythmia inducibility has relevantly improved the clinical outcome of the PAF control strategy.

Cited by 16 publications

References 24 publications

Long-Term Clinical Comparison of Procedural End Points After Pulmonary Vein Isolation in Paroxysmal Atrial Fibrillation

Long-Term Clinical Comparison of Procedural End Points After Pulmonary Vein Isolation in Paroxysmal Atrial Fibrillation

Clinical Utility of Intravenous Nifekalant Injection during Radiofrequency catheter Ablation for Persistent Atrial Fibrillation

Prevalence and Predictors of Additional Ablation Beyond Pulmonary Vein Isolation in Patients With Paroxysmal Atrial Fibrillation

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