Adjunctive substrate modulation after pulmonary vein isolation has no benefit in strictly paroxysmal atrial fibrillation: a randomized prospective study

Abstract

Introduction: Single procedure success rates of pulmonary vein isolation (PVI) in patients with paroxysmal atrial fibrillation (PAF) are still unsatisfactory. In patients with persistent AF adjunctive ablation of complex fractionated atrial electrograms (CFAE) is frequently used to improve outcome. We hypothesized that a subgroup of PAF-patients with sustained AF acutely after PVI might also benefit from additional CFAE-ablation. Methods: Overall 1032 consecutive patients received a first catheter ablation of strictly PAF between 08/2008-12/2012. In most patients AF was either not inducible or terminated during PVI. AF sustained after successful PVI in 61 patients (6%), who were randomized to either cardioversion (PVI-alone, n=30) or additional CFAE-ablation (PVI+CFAE, n=31). Primary endpoint was the reoccurrence of AF/AT. Results: Randomized patients had an AF-history of 62±8 months with max. episodes of 15±2 hours. Procedure-duration (126±6 vs 171±9 min), radiofrequency (RF) application- (44±3 vs 72±5 min) and fluoroscopy time (26±2 vs 40±2 min) were longer in PVI+CFAE (all p<0.001). In the PVI+CFAE group in 27/31 (87%) patients AF was terminated by ablation. There was no significant difference between the groups with respect to freedom of AF/AT (see graph). Subsequently, 10/11 (91%) patients with recurrences in PVI-alone and 11/12 (92%) in PVI+CFAE underwent further intervention (p=ns). Overall, 26/30 (87%) vs 26/31 (84%, p=ns) were free from AF/AT after 1,4±0,1 vs 1,5±0,2, (p=ns) procedures. ![Figure][1] Figure 1. Patients free from atrial arrhythmia (%) Conclusion: The proportion of patients with sustained AF after PVI in a patient-cohort with strictly PAF is low. In terms of AF/AT-recurrence, these patients do not benefit from further CFAE-guided ablation compared to PVI alone, but are exposed to longer procedure-, fluoroscopy and RF-duration. [1]: pending:yes