Five-Year Outcome of Catheter Ablation of Persistent Atrial Fibrillation Using Termination of Atrial Fibrillation as a Procedural Endpoint | Journal Scan

Study Questions:

What is the long-term success rate of a stepwise radiofrequency catheter ablation strategy for persistent atrial fibrillation (AF)?


One hundred fifty patients (mean age 57 years) with persistent AF (longstanding in 65%) underwent stepwise ablation, consisting of pulmonary vein isolation, then ablation of complex electrograms, then linear ablation, with the endpoint of AF termination. The patients underwent evaluation (including a 1- to 7-day Holter monitor) at least every 6 months. The primary endpoint was freedom from any atrial tachyarrhythmia lasting >30 seconds off antiarrhythmic drug therapy after the last ablation procedure.


Termination of AF by ablation was achieved in 80% of patients. The median number of procedures/patient was 2.1. The primary endpoint was achieved after the last ablation procedure in 90%, 80%, and 63% of patients at 1, 2, and 5 years of follow-up, respectively. Independent predictors of arrhythmia recurrence after multiple procedures were failure to terminate AF by ablation (hazard ratio [HR], 3.8), left atrial diameter ≥50 mm (HR, 2.1), continuous AF duration ≥18 months (HR, 2.0), and structural heart disease (HR, 1.9).


The authors concluded that sinus rhythm is restored long-term by a stepwise ablation strategy in a majority of patients with persistent AF. Failure to terminate AF by ablation is predictive of recurrent AF.


Based on the success rates reported in this study, it seems unlikely that any other ablation strategy could result in better outcomes. However, whether the stepwise approach is superior to less aggressive ablation strategies is far from settled. There continue to be a large proportion of ablationists who believe that “less is more” when ablating persistent AF.

Clinical Topics: Arrhythmias and Clinical EP, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: Anti-Arrhythmia Agents, Arrhythmias, Cardiac, Atrial Fibrillation, Catheter Ablation, Electrocardiography, Ambulatory, Heart Atria, Pulmonary Veins, Tachycardia, Supraventricular

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