Effect of Catheter Ablation Using Pulmonary Vein Isolation With vs Without Posterior Left Atrial Wall Isolation on Atrial Arrhythmia Recurrence in Patients With Persistent Atrial Fibrillation

Author:

Kistler Peter M.12345,Chieng David1234,Sugumar Hariharan1234,Ling Liang-Han1234,Segan Louise1234,Azzopardi Sonia12,Al-Kaisey Ahmed36,Parameswaran Ramanathan36,Anderson Robert D.36,Hawson Joshua36,Prabhu Sandeep1237,Voskoboinik Aleksandr1234,Wong Geoffrey36,Morton Joseph B.36,Pathik Bhupesh36,McLellan Alex J.368,Lee Geoffrey36,Wong Michael369,Finch Sue3,Pathak Rajeev K.1011,Raja Deep Chandh1011,Sterns Laurence12,Ginks Matthew13,Reid Christopher M.514,Sanders Prashanthan15,Kalman Jonathan M.356

Affiliation:

1. The Baker Heart and Diabetes Research Institute, Melbourne, Australia

2. The Alfred Hospital, Melbourne, Australia

3. University of Melbourne, Melbourne, Australia

4. Cabrini Hospital, Melbourne, Australia

5. Monash Health, Melbourne, Australia

6. Royal Melbourne Hospital, Melbourne, Australia

7. Mulgrave Private Hospital, Melbourne, Australia

8. St Vincent’s Private Hospital Fitzroy, Melbourne, Australia

9. Epworth Hospital Richmond, Melbourne, Australia

10. Canberra Hospital, Australian Capital Territory, Australia

11. Australian National University, Australian Capital Territory, Australia

12. Royal Jubilee Hospital, Vancouver Island, British Columbia, Canada

13. John Radcliffe Hospital, Oxford, United Kingdom

14. Curtin University, Perth, Australia

15. Royal Adelaide Hospital, Adelaide, Australia

Abstract

ImportancePulmonary vein isolation (PVI) alone is less effective in patients with persistent atrial fibrillation (AF) compared with paroxysmal AF. The left atrial posterior wall may contribute to maintenance of persistent AF, and posterior wall isolation (PWI) is a common PVI adjunct. However, PWI has not been subjected to randomized comparison.ObjectiveTo compare PVI with PWI vs PVI alone in patients with persistent AF undergoing first-time catheter ablation.Design, Setting, and ParticipantsInvestigator initiated, multicenter, randomized clinical trial involving 11 centers in 3 countries (Australia, Canada, UK). Symptomatic patients with persistent AF were randomized 1:1 to either PVI with PWI or PVI alone. Patients were enrolled July 2018-March 2021, with 1-year follow-up completed March 2022.InterventionsThe PVI with PWI group (n = 170) underwent wide antral pulmonary vein isolation followed by posterior wall isolation involving linear ablation at the roof and floor to achieve electrical isolation. The PVI-alone group (n = 168) underwent wide antral pulmonary vein isolation alone.Main Outcomes and MeasuresPrimary end point was freedom from any documented atrial arrhythmia of more than 30 seconds without antiarrhythmic medication at 12 months, after a single ablation procedure. The 23 secondary outcomes included freedom from atrial arrhythmia with/without antiarrhythmic medication after multiple procedures, freedom from symptomatic AF with/without antiarrhythmic medication after multiple procedures, AF burden between study groups at 12 months, procedural outcomes, and complications.ResultsAmong 338 patients randomized (median age, 65.6 [IQR, 13.1] years; 76.9% men), 330 (97.6%) completed the study. After 12 months, 89 patients (52.4%) assigned to PVI with PWI were free from recurrent atrial arrhythmia without antiarrhythmic medication after a single procedure, compared with 90 (53.6%) assigned to PVI alone (between-group difference, –1.2%; hazard ratio [HR], 0.99 [95% CI, 0.73-1.36]; P = .98). Of the secondary end points, 9 showed no significant difference, including freedom from atrial arrhythmia with/without antiarrhythmic medication after multiple procedures (58.2% for PVI with PWI vs 60.1% for PVI alone; HR, 1.10 [95% CI, 0.79-1.55]; P = .57), freedom from symptomatic AF with/without antiarrhythmic medication after multiple procedures (68.2% vs 72%; HR, 1.20 [95% CI, 0.80-1.78]; P = .36) or AF burden (0% [IQR, 0%-2.3%] vs 0% [IQR, 0%-2.8%], P = .47). Mean procedural times (142 [SD, 69] vs 121 [SD, 57] minutes, P < .001) and ablation times (34 [SD, 21] vs 28 [SD, 12] minutes, P < .001) were significantly shorter for PVI alone. There were 6 complications for PVI with PWI and 4 for PVI alone.Conclusions and RelevanceIn patients undergoing first-time catheter ablation for persistent AF, the addition of PWI to PVI alone did not significantly improve freedom from atrial arrhythmia at 12 months compared with PVI alone. These findings do not support the empirical inclusion of PWI for ablation of persistent AF.Trial Registrationanzctr.org.au Identifier: ACTRN12616001436460

Publisher

American Medical Association (AMA)

Subject

General Medicine

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