Sequential Biatrial Linear Defragmentation Approach for Persistent Atrial Fibrillation

Study Questions:

How often does sequential linear ablation terminate and prevent recurrences of persistent atrial fibrillation (AF)?


One hundred thirty-five patients (mean age 62.4 years) with persistent AF (long-standing in 56%) underwent radiofrequency catheter ablation using a standardized strategy until termination of AF. Antral pulmonary vein isolation was followed by linear ablation in the following sequence: left atrial roof, posterior wall, septum, inferior wall, base of left atrial appendage, anterior wall, then right atrial septum, crista terminalis, and base of right atrial appendage. Atrial tachycardias (ATs) were mapped and ablated. Holter monitors and/or event monitors were performed at regular intervals during follow-up.


AF terminated by ablation in 51% of patients, most often (85%) during left atrial ablation, and most often (70%) with conversion to AT. Freedom from AF/AT after a single procedure was 33% at 1 year. After a mean of 1.7 procedures/patient, freedom from AF/AT was 74% at a mean follow-up of 15 months.


Extensive linear ablation in a prespecified sequence terminates persistent AF in approximately 50% of patients. This strategy has fairly good efficacy at 15 months of follow-up, but only after redo procedures.


The strategy used in this study is a variation on the stepwise approach for ablation of persistent AF, the difference being that complex fractionated atrial electrograms (CFAEs) were not individually targeted. However, linear ablation was performed at sites of high CFAE prevalence. Unfortunately, CFAEs are highly nonspecific markers of AF rotors or focal sources. This explains the low acute AF termination rate and the poor clinical results after one procedure. New techniques for identifying AF rotors and focal sources hold great promise for improving the efficiency and efficacy of AF ablation.

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

Keywords: Carbamates, Tachycardia, Supraventricular, Follow-Up Studies, Heart Atria, Salmonella enterica, Pulmonary Veins, Electrophysiologic Techniques, Cardiac, Heart Rate, Atrial Septum, Recurrence, Atrial Appendage, Catheter Ablation

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