Appropriate selection of substrate ablation in patients with persistent atrial fibrillation using an on-day assessment of baseline rhythm and trigger origin

Abstract

Abstract Background It has not been fully elucidated which patients with persistent atrial fibrillation (PerAF) should undergo substrate ablation. Purpose To identify the appropriate patients with PerAF who required an additional substrate ablation plus pulmonary vein isolation (PVI) using an on-day assessment of the baseline rhythm during the procedure and origin of the AF trigger. Methods This study was a post hoc sub-analysis of the EARNEST-PVI (Effect of Extensive Ablation on Recurrence in Patients with Persistent AF Treated with Pulmonary Vein Isolation) trial, which was a prospective, multicenter, randomized, open-label trial, comparing the PVI-alone and PVI-plus arms. The patients were divided into 2 groups according to the baseline rhythm and origin of the AF trigger. AF trigger was induced before catheter ablation using isoproterenol infusion (maximum dose of 0.4 μg/kg/min). Proven pulmonary vein (PV) triggers were defined as reproducible AF triggers from only the PVs. Group A consisted of patients with sinus rhythm at the baseline or proven PV triggers. Proven PV triggers were defined as reproducible AF triggers from only the PVs. Group B consisted of the remaining patients, who were AF at baseline and had non-proven PV triggers. The arrhythmia-free survival after a 3-month blanking period was assessed. Results Among the group A patients (n=327, Figure 1), the arrhythmia-free survival did not significantly differ between the PVI-alone and PVI-plus arms (p=0.276, HR 1.22, 95% CI: 0.85-1.76) (Figure 2, upper panel). Among the group B patients (n-166, Figure 1), who had AF at baseline and non-PV triggers, the arrhythmia-free survival was significantly lower in the PVI-alone than PVI-plus arm (p=0.032, HR 1.68, 95% CI: 1.04-2.70) (Figure 2 lower panel). Conclusion The on-day assessment of the baseline rhythm and trigger origin could distinguish patients who benefited from an additional ablation plus PVI. With an additional ablation plus PVI, the patients with sinus rhythm at baseline or who had proven PV triggers did not receive any benefit, whereas those with AF at baseline and no proven PV triggers received a benefit.Figure 1Figure 2