Substrate modification combined with pulmonary vein isolation improves outcome of catheter ablation in patients with persistent atrial fibrillation: a prospective randomized comparison

Willems, Stephan; Klemm, Hanno; Rostock, Thomas; Brandstrup, Benedikt; Ventura, Rodolfo; Steven, Daniel; Risius, Tim; Lutomsky, Boris; Meinertz, Thomas

doi:10.1093/eurheartj/ehl093

Cited by 274 publications

(246 citation statements)

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“…5,8,10 Furthermore, additional linear ablation demonstrated better clinical outcomes in another 3 randomized trials. 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.…”

Section: Current Ablation Strategies For Chronic Afmentioning

confidence: 96%

“…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.…”

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confidence: 99%

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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

138

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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Section: Current Ablation Strategies For Chronic Afmentioning

confidence: 96%

mentioning

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

138

105

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“…Linear ablation of mitral isthmus between the mitral annulus and the left inferior PV can significantly modify AF substrate [53]. Completeness and transmurality of linear lesions are very important for the successful treatment of AF as well as for the prevention of iatrogenic atrial tachycardia after ablation [54]. Linear ablation leads to compartmentalization of the LA and reduction of the area with CFAE, thus resulting in an additional AF cycle length increase, which can be critical for the AF termination during a stepwise approach to the ablation of longstanding persistent AF [55].…”

Section: Figure 2 Catheter Ablation Of Paroxysmal Af: Elimination Ofmentioning

confidence: 99%

“…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].…”

Section: Phrenic Nerve Injurymentioning

confidence: 99%

Catheter Ablation of Lone Atrial Fibrillation

Mujović

Marinković²,

Potpara³

et al. 2014

CPD

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Atrial fibrillation is the most common sustained arrhythmia in clinical practice, associated with increased mortality, risk of stroke and heart failure, as well as the reduction of the quality of life. Atrial fibrillation may be encountered in young otherwise healthy individuals, due to the isolated electrophysiological disorder limited mostly to the pulmonary veins and posterior left atrial wall, or associated with the presence of advanced underlying heart disease and numerous cardiac and non-cardiac comorbidities with significant structural remodeling of the atrial myocardium. Due to limited efficacy and serious side effects of antiarrhythmic drugs, catheter ablation of atrial fibrillation, based on the pulmonary vein isolation for paroxysmal atrial fibrillation and adjunctive substrate modification for persistent atrial fibrillation, has emerged as an attractive and promissing alternative therapeutic option for selected patients with atrial fibrillation. In this review article, we discuss the electrophysiological left atrial abnormalities underlying lone atrial fibrillation and the role of pulmonary veins in pathophysiology of arrhythmia, and we summarize results of the studies on the long term outcome of catheter ablation of atrial fibrillation, as well as the studies on comparison of antiarrhythmic drugs with catheter ablation for treatment of atrial fibrillation. In addition, we present available data that provide better understanding of mechanisms, diagnosis, prevention and treatment of specific procedure-related complications and discuss current periprocedural anticoagulation strategies and their impact on the thromboembolic risk reduction.

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“…1,30) This discrimination also enables evaluation of catheter ablation efficacy as well as the necessity of additional procedures for standard pulmonary vein isolation, ie, linear ablation, continuous fractionated atrial electrogram ablation, and/or ganglionated plexi ablation. 1,4,31,32) Additionally, because the discrimination of PAF and persistent AF patients in the present study population was in "new-onset AF" patients, the present results are applicable for "first documented AF" patients. To the best of our knowledge, this is the first report which stated the parameters to discriminate between PAF and persistent AF patients in cases with "new-onset" AF.…”

Section: Parameters To Discriminate Between Paf and Persistent Afmentioning

confidence: 79%

Discrimination of Paroxysmal and Persistent Atrial Fibrillation in Patients With New-Onset Atrial Fibrillation

et al. 2016

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SummaryDiscrimination between paroxysmal and persistent atrial fibrillation (PAF and persistent AF) is important for determining the therapeutic strategy in patients with new-onset AF. We evaluated various clinical factors and P wave morphology to discriminate PAF and persistent AF patients in patients with new-onset AF.The study population consisted of 79 patients with new-onset AF (70.3 ± 10.8 years, female:male 33:46) who were retrospectively selected from 8,632 AF patients in the Kitasato University Hospital ECG storing system. PAF (n = 38) and persistent AF (n = 41) patients were diagnosed by whether the initial PAF episode continued for 1 week. The P wave morphologies were analyzed using the most recent 12 lead-ECG recording of sinus rhythm. P wave dispersion was defined as the difference between the maximum and minimum durations of all leads. Along with these data, various clinical factors were evaluated and compared between PAF and persistent AF patients.Multivariate analysis identified P wave dispersion (56.6 ± 14.8 versus 66.5 ± 12.8 msec, P = 0.002) and left atrial dimension (LAD: 40.2 ± 7.0 versus 47.7 ± 8.2 mm, P < 0.001) as independent factors for discrimination between PAF and persistent AF patients. Combining these two parameters achieved a specificity of 88.9%, a positive predictive value of 81.8%, a sensitivity of 95.3%, and a negative predictive value of 88.9%.In patients with new-onset AF, P wave dispersion and LAD were independent factors for discrimination between PAF and persistent AF. (Int Heart J 2016; 57: 573-579) Key words: P wave I n clinical practice, identification of the clinical stage of atrial fibrillation (AF) is an important issue to enable clinicians to determine a therapeutic strategy, especially in patients with new-onset AF, in whom it is important to determine the indication of antiarrhythmic agents or catheter ablation.1-3) When considering catheter ablation for AF, it is important to identify the early stage of AF, ie, paroxysmal atrial fibrillation (PAF), because the efficacy of catheter ablation is higher in PAF patients, and the ablation procedure itself can be simplified. 4,5) Recently, we have reported that P wave analysis in the 12-lead ECG of sinus rhythm is useful in determining the emergence of AF in clinical cases. 6) We have shown that the P wave amplitude in lead II or V1 was higher, and P wave dispersion, ie, the dispersion of P wave duration, was larger in patients with new-onset AF compared with control patients without AF.6) Therefore, we hypothesized that the clinical stage of AF may also be identified by P wave analysis, as well as with the other clinical parameters. In the present study, we retrospectively identified patients with new-onset AF in the digital ECG profiling system of our hospital. Patients were classified into PAF and persistent AF by their clinical course in accordance with the definitions in the AHA/ACC/ESC guidelines and JCS guidelines.7,8) P waves in the preceding sinus rhythm state were analyzed as the precursor state for new-onset ...

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Substrate modification combined with pulmonary vein isolation improves outcome of catheter ablation in patients with persistent atrial fibrillation: a prospective randomized comparison

Abstract: PVI alone is insufficient in the treatment of persistent AF. However, additional left linear lesions increase the success rate significantly. Early AF-relapses are associated with a negative outcome after PVI alone but not following additional SM.

Cited by 274 publications

References 39 publications

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

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

Catheter Ablation of Lone Atrial Fibrillation

Discrimination of Paroxysmal and Persistent Atrial Fibrillation in Patients With New-Onset Atrial Fibrillation

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