Long-term outcomes of empirical extra-pulmonary vein linear ablation in patients with persistent atrial fibrillation

Abstract

\n \n \n Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by grants [HI18C0070] and [HI19C0114] from the Korea Health 21 R&D Project, Ministry of Health and Welfare, and a grant [NRF-2020R1A2B01001695] from the Basic Science Research Program run by the National Research Foundation of Korea (NRF).\n \n \n \n Although extra-pulmonary vein (PV) left atrial (LA) linear ablation has been performed during catheter ablation (CA) of persistent atrial fibrillation (PeAF), the long-term efficacy and safety of this procedure have not yet been verified.\n \n \n \n We investigated whether an anterior line (AL) and posterior box ablation (POBA) in addition to circumferential PV isolation (CPVI) improves the rhythm without worsening the LA function in PeAF patients.\n \n \n \n We retrospectively compared the additional AL\u2009+\u2009POBA and CPVI alone groups in 604 patients with PeAF who underwent regular rhythm follow-ups (16.9%; males 79.3%, 58.5\u2009±\u200910.7 years of age) after propensity score matching. The primary endpoint was AF recurrence after single procedures and secondary endpoints were the cardioversion rate, response to anti arrhythmic drugs, LA changes, and re-conduction rates of the de-novo ablation lesion set.\n \n \n \n After a mean follow-up of 45.2\u2009±\u200933.6 months, the clinical recurrence rate did not significantly differ between the two groups (log-rank p\u2009=\u20090.554) despite longer procedure times in the AL\u2009+\u2009POBA group (p\u2009<\u20090.001). Atrial tachycardia recurrences (p\u2009=\u20090.001) and the cardioversion rates after ablation (p\u2009<\u20090.001) were higher in the AL\u2009+\u2009POBA group than CPVI group. AL\u2009+\u2009POBA was associated with better rhythm outcomes in patients with large anterior LA volume indices (p for interaction 0.037) and low mean LAA(left atrial appendage) voltages (p for interaction 0.019). In repeat procedures, the LA pulse pressure elevation was significant after the AL\u2009+\u2009POBA.\n \n \n \n In patients with PeAF, an AL\u2009+\u2009POBA in addition to the CPVI did not improve the rhythm outcomes nor influence the long-term safety, and lead to more extended procedures. Procedure outcomes OverallAL\u2009+\u2009POBACPVIp-value(n\u2009=\u2009604)(n\u2009=\u2009302)(n\u2009=\u2009302)Procedure time, min190.8\u2009±\u200962.6226.9\u2009±\u200949.4154.6\u2009±\u200952.8<0.001Ablation time, sec5079\u2009±\u200919566420\u2009±\u200913723738± 1475<0.001Overall complications24 (4.0)13 (4.3)11 (3.6)0.835Early recurrence, n (%)277 (45.9)129 (42.7)148 (49.0)0.142Recurrence type AT, n (% in early recur)77 (27.8)51 (39.5)26 (17.6)<0.001Clinical recurrence within 1-year, n(%)116 (19.2)52 (17.2)65 (21.5)0.256Recurrence type AT, n (% in clinical recur)60 (23.1)46 (30.7)14 (12.7)0.001Cardioversion, n (% in total recur/ % overall)105 (40.4/17.4)74 (49.3/24.5)31 (28.1/10.3)<0.001POBA, posterior box ablation; AL, anterior line; CPVI, circumferential pulmonary vein isolation; AT, atrial tachycardia;Abstract Figure. Long term ablation outcome\n