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PVI With vs. Without Posterior Wall Isolation for Persistent AF
Quick Takes
- In a large, randomized trial of patients with persistent AF, there was no significant difference in 12-month freedom from recurrent atrial arrhythmia after a single procedure among those with pulmonary vein isolation (PVI) and posterior left atrial wall isolation compared with PVI alone.
- Additional ablation was not associated with significantly increased complications.
Study Questions:
Does adding posterior wall isolation (PWI) to pulmonary vein isolation (PVI) improve success in patients with persistent atrial fibrillation (AF) undergoing first-time catheter ablation?
Methods:
CAPLA was a multicenter, randomized clinical trial, in which symptomatic patients with persistent AF were randomized to either PVI with PWI or PVI alone. The primary endpoint was freedom from any documented atrial arrhythmia of >30 seconds at 12 months, after a single ablation procedure.
Results:
A total of 170 patients underwent wide antral PVI followed by linear ablation at the roof and floor of the left atrium to achieve electrical isolation of the posterior wall (PVI with PWI group). The PVI-alone group (n = 168) underwent wide antral PVI alone. After 12 months, 89 patients (52%) assigned to PVI with PWI were free from recurrent atrial arrhythmia without antiarrhythmic medication after a single procedure, compared with 90 (54%) assigned to PVI alone (p = 0.98). There were six complications for PVI with PWI and four for PVI alone.
Conclusions:
The authors concluded that the addition of PWI to PVI did not improve freedom from atrial arrhythmia compared with PVI alone.
Perspective:
Catheter ablation is superior to drug therapy for the maintenance of sinus rhythm in patients with AF. The success rate of ablation for persistent AF is significantly lower than for paroxysmal AF. Various adjunctive ablation strategies targeting sources outside of the pulmonary veins and left and right atrial substrate have been pursued in patients with persistent AF with mostly disappointing results. Postulated benefits of the PWI, performed in the present study, are the isolation of the septo-pulmonary bundle, autonomic ganglia modification, targeting regions of fibrosis or complex fractionated activity, and reinforcement of PVI. One explanation for the current findings is that the more extensive ablation may be proarrhythmic. The results of this study, although disappointing, do not necessarily mean that PWI is of no benefit in other categories of patients, such as those who have recurrent AF following PVI, low posterior wall voltage, or longer-standing persistent AF. Further studies are needed to elucidate whether any patients benefit from the additional ablation.
Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure
Keywords: Anti-Arrhythmia Agents, Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Catheter Ablation, Heart Failure, Pulmonary Veins
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