Randomized Ablation Strategies for the Treatment of Persistent Atrial Fibrillation: RASTA Study

Study Questions:

What is the most effective ablation strategy for persistent atrial fibrillation (AF)?

Methods:

One hundred fifty-six patients (mean age 58 years) with persistent AF (mean duration 47 months) were randomly assigned to one of the following radiofrequency catheter ablation (RFCA) strategies: 1) pulmonary vein isolation (PVI) and RFCA of nonpulmonary vein (nPV) triggers guided by a stimulation protocol (n = 55); 2) PVI and empiric RFCA at common nPV sites (mitral annulus, crista terminalis, Eustachian ridge, limbus of fossa ovalis, superior vena cava; n = 50); and 3) PVI plus RFCA of left-sided complex fractionated atrial electrograms (CFAEs; n = 51). PVI was accomplished in all groups by wide-area circumferential ablation. Serial 30-day transtelephonic monitoring was performed during follow-up. The primary endpoint was freedom from AF/atrial tachycardia off antiarrhythmic drugs at 1 year after one ablation procedure.

Results:

The primary endpoint was achieved significantly more often in groups 1 (49%) and 2 (58%) than in group 3 (29%). AF recurrence at <6 weeks and randomization to group 3 were the only independent predictors of an unsuccessful outcome. A redo procedure was performed in 37% of patients. At a mean follow-up of 22 months, freedom from AF was similar in groups 1 (53%), 2 (62%), and 3 (51%).

Conclusions:

In patients with persistent AF, PVI plus ablation of nPV triggers is more efficacious than PVI plus CFAE ablation.

Perspective:

A prior meta-analysis demonstrated that CFAE ablation has incremental value after PVI in patients with persistent AF. The incremental value of CFAE ablation in this study is unclear because no patients underwent only PVI. In any event, the results suggest that nPV triggers play an important role in persistent AF.

Clinical Topics: Arrhythmias and Clinical EP, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: Tachycardia, Supraventricular, Pulmonary Veins, Breast Neoplasms, Catheter Ablation, Pregnancy, Mitral Valve, Vena Cava, Superior


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