In Ablation of Persistent Atrial Fibrillation, More Is Not Necessarily Better

May 27, 2015

In Ablation of Persistent Atrial Fibrillation, More Is Not Necessarily Better

  1. Mark S. Link, MD

In an international trial of ablation strategies, straightforward pulmonary-vein isolation had an efficacy similar to that of more-complex ablations.

  1. Mark S. Link, MD

For the ablation of paroxysmal atrial fibrillation (AF), there is general consensus that the optimal initial strategy is electrical isolation of pulmonary veins (PVI). Whether PVI is best performed by radiofrequency, cryoablation, or potentially newer techniques is not entirely clear. However, for persistent and permanent AF, it is believed that PVI needs to be accompanied by more-extensive ablation — of roof and mitral lines, high-frequency potentials, or rotors. In an industry-funded trial, investigators in 12 countries randomized 589 individuals with persistent AF (mean age, 60; 78% men) to one of three radiofrequency ablation strategies: PVI alone, PVI plus roof and mitral linear ablation, or PVI plus ablation of high-frequency potentials. Randomization was performed in a 1:4:4 ratio because PVI alone was believed to be an inferior approach.

Freedom from Atrial Fibrillation
Kaplan-Meier estimates of freedom from documented AF >30 seconds after a single procedure show no significant differences between groups.Adapted with permission from the New England Journal of Medicine (N Engl J Med 2015 May 7; 372:1812).
Freedom from Atrial Fibrillation

Kaplan-Meier estimates of freedom from documented AF >30 seconds after a single procedure show no significant differences between groups.

Adapted with permission from the New England Journal of Medicine (N Engl J Med 2015 May 7; 372:1812).

Not surprisingly, procedure times were significantly shorter in the PVI-only group. At 18 months, rates of being free of an AF recurrence lasting >30 seconds were no different in the three arms (PVI alone, 59%; PVI plus lines, 46%; PVI plus complex electrograms, 49%). Repeat ablations were performed in 21% of the PVI-alone group, 33% in the PVI plus lines group, and 26% in the PVI plus complex electrograms group; see Figure, which shows the Kaplan-Meier estimates (N Engl J Med 2015; 372:1812).

Serious adverse events were three cardiac tamponades, three strokes, and one atrioesophageal fistula.

Comment

The study results are surprising to me. I and most electrophysiologists, including those designing the current study, would have expected PVI alone to be inferior. Although not the final word on the optimal ablation of persistent AF, these findings argue for simplicity in ablation of persistent AF. Yet, in all three study arms, recurrent AF was common and present in approximately 50%, showing that we need better strategies for AF management in this patient population.

Editor Disclosures at Time of Publication

  • Disclosures for Mark S. Link, MD at time of publication Grant / Research support Unequal Technologies Editorial boards UpToDate; Heart Rhythm Leadership positions in professional societies Heart Rhythm Society (Chair, CME Compliance Committee); American Heart Association (Chair, ACLS Writing Group; Member, Emergency Cardiovascular Care)

Citation(s):

Reader Comments (3)

JAMES SPENGLER Other Healthcare Professional, Emergency Medicine

I have had two ablations. One for A fibb and one for A flutter. I still had reaccurant A fibb episodes until I changed my diet and exercise regimen .

frank sutton Physician, Family Medicine/General Practice, retired

Any difference between chad 2,or chad 3 in a-fib patients who have had unknown cause of bleeding in three past surgeries?

garrick kantzler Physician, Geriatrics

I have a patient with PAF who is still having episodes of PAF after 2 PV ablations. Her electrophysiologist is recommending a pacemaker and AV ablation. Should she try more PV ablations first. How many PV ablations can one have?

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