Re-ablation of Persistent Atrial Fibrillation: a Randomized Study, Evaluating Vein of Marshall Ethanol Ablation in Combination With Block of Mitral and Tricuspid Isthmuses and Dome Line
Phase: NA
Conditions: Atrial Fibrillation, Persistent
Sponsor: Aarhus University Hospital

RE-ABLATION OF 
PERSISTENT ATRIAL FIBRILLATION: 
A RANDOMIZED STUDY, EVALUATING VEIN OF MARSHALL 
ETHANOL ABLATION IN COMBINATION WITH BLOCK           
OF MITRAL AND TRICUSPID ISTHMUSES AND DOME LINE 
 
 
An investigator initiated, randomized, patient-assessor blinded multi-center trial 
Sponsor: Aarhus University Hospital 
 
 
 
Participating centres: 
Department of Cardiology, Aarhus University Hospital (Mads Brix Kronborg, Peter Lukac, Steen Buus Kristi-
ansen, Jens Kristensen, Henrik Kjærulf Jensen, Christoffer Tobias Witt) 
Department of Cardiology, Karolinska University Hospital, Stockholm (Finn Åkerström, Nikola Drca, Serkan 
Saygi) 
Department of Cardiology, Leiden University Medical Center (Hadrian Wijnmaalen, Sebastiaan Piers) 
 
 
 
Protocol version: 3.0 
Name of Document:  Re-AF study 
Date: 17-11-2024 
 
 

Re-AF study 
Department of Cardiology 
Aarhus University Hospital 
 
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Table of contents 
Table of contents ............................................................................................................................................ 2 
List of abbreviations ........................................................................................................................................ 4 
Protocol overview ............................................................................................................................................ 5 
1.0 Background .................................................................................................................................................. 7 
2.0 Aim ............................................................................................................................................................... 8 
2.1 Hypothesis ............................................................................................................................................... 8 
3.0 Methods ...................................................................................................................................................... 8 
3.1 Study conduct .......................................................................................................................................... 8 
3.2 Study design ............................................................................................................................................ 8 
3.3 Definition of persistent atrial fibrillation ................................................................................................. 9 
3.4 Eligibility criteria ...................................................................................................................................... 9 
3.4.1 Inclusion criteria: ........................................................................................................................... 9 
3.4.2 Exclusion criteria: .............................................................................................................................. 9 
3.4 Power calculation .................................................................................................................................... 9 
3.5 Study endpoints ..................................................................................................................................... 10 
3.6 Supplementary study parameters ......................................................................................................... 10 
3.7 Strategy for the procedure .................................................................................................................... 11 
3.10 Follow up ............................................................................................................................................. 12 
3.11 Statistics and data analysis plan  ......................................................................................................... 12 
3.12 Randomization ..................................................................................................................................... 12 
4.0 RECRUITMENT OF PARTICIPANTS .............................................................................................................. 13 
4.1 Consent to participate ........................................................................................................................... 13 
4.2 Insurance ............................................................................................................................................... 13 
5.0 ETHICAL ASPECTS ....................................................................................................................................... 13 
5.1 Risks and inconvenience ........................................................................................................................ 13 
5.2 Beneficial effects ................................................................................................................................... 14 
6.0 BIO BANK ................................................................................................................................................... 14 
7.0 Data collection, processing, and storage ................................................................................................... 14 
7.1 Monitoring ............................................................................................................................................. 14 
7.2 Data Collection ...................................................................................................................................... 14 
7.3 Data reporting ....................................................................................................................................... 14 
7.4 Source Documentation .......................................................................................................................... 14 
7.5 Data update ........................................................................................................................................... 15 

Re-AF study 
Department of Cardiology 
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7.5 Access to patient related information ................................................................................................... 15 
7.6 Final Data Analyses ................................................................................................................................ 15 
8.0 QUALITY ASSURANCE ................................................................................................................................ 15 
9.0 ECONOMICS ............................................................................................................................................... 15 
10.0 ADDITIONAL STUDY INFORMATION ........................................................................................................ 16 
11.0 PUBLICATION POLICY ............................................................................................................................... 16 
12.0 LITERATURE……………..…………………………………………………………………………………………………………………………21 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Re-AF study 
Department of Cardiology 
Aarhus University Hospital 
 
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List of abbreviations 
AF Atrial fibrillation 
AFEQT: Atrial Fibrillation Effect on Quality of Life 
AAD: Antiarrhythmic drugs 
CFAE: Complex Fractionated Atrial Electrograms 
CTI: Cavotricuspid Isthmus  
DC: Direct Current 
ECG: Electrocardiogram 
LA: Left atrium 
PAF: Paroxysmal atrial fibrillation 
PsAF: Persistent atrial fibrillation 
PV: Pulmonary Vein 
PVI: Pulmonary Vein Isolation   
QoL: Quality of Life 
VOM: Vein of Marshall  
 

Re-AF study 
Department of Cardiology 
Aarhus University Hospital 
 
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Protocol overview 
Title 
RE-ABLATION OF PERSISTENT ATRIAL FIBRILLATION: 
A RANDOMIZED STUDY, EVALUATING VEIN OF MARSHALL ETHANOL ABLATION IN 
COMBINATION WITH BLOCK OF MITRAL AND TRICUSPID ISTHMUSES AND DOME LINE 
Acronym 
Re-AF study 
Study design 
An investigator initiated, randomized, patient-assessor blinded multi-
center trial 
Participating centers Department of Cardiology, Aarhus University Hospital 
Department of Cardiology, Karolinska University Hospital, Stockholm 
Department of Cardiology, Leiden University Medical Center 
Hypotheses 
Addition of Vein of Marshall ethanol ablation in combination with block of 
mitral and tricuspid isthmuses and dome line to standard pulmonary vein 
re-isolation improves quality of life and reduces recurrence of atrial ar-
rhythmias as compared to standard pulmonary vein re-isolation alone in 
patients undergoing re-ablation for persistent atrial fibrillation.   
Eligibility criteria 
Inclusion criteria: 
 Previous pulmonary vein isolation for atrial fibrillation 
 Indication for catheter ablation with at least two episodes of 
symptomatic PsAF during the last 12 months 
 Age  18 years 
 Expected survival   12 months 
 Able to provide informed consent 
 
Exclusion criteria: 
 Previous extrapulmonary atrial ablation other than cavotricuspid 
isthmus line, roof- or dome line or posterior wall isolation/abla-
tion 
 Atypical atrial flutter in addition to atrial fibrillation 
 Atrial fibrillation secondary to a transient abnormality 
 Uncontrolled hypertension 
 Acute coronary syndrome, cardiac surgery, or TIA/stroke within 
the last 3 months 
 Planned cardiac surgery within 1 year 
 Dialysis or severe renal failure 
 Active substance or alcohol abuse (>14 units/week) 

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Department of Cardiology 
Aarhus University Hospital 
 
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Randomization and 
conduct of the 
study 
In a patient-assessor blinded, randomized multi-center study, consecutive 
patients undergoing re-ablation for persistent atrial fibrillation are ran-
domized (1:1) to: 1) standard therapy including re-isolation of pulmonary 
veins (control group) or 2) re-isolation of pulmonary veins and vein of Mar-
shall ethanol ablation in combination with block of mitral and tricuspid 
isthmuses and dome line (intervention group). Patients are followed with 
standard ECG at 3 months, with standard ECG, 5-days’ ECG monitoring and 
quality of life assessment after 12 months, with standard ECG and quality 
of life assessment after 24 months, through patient files at 60 months af-
ter the ablation.   
Primary endpoint 
Change in AFEQT score between baseline and 12 months.  
Safety endpoints 
Peri- or postprocedural complications (vascular complication needing in-
tervention, conduction disturbances requiring a pacemaker, gastroesoph-
ageal fistula, phrenic nerve damage, stroke or systemic embolism, pulmo-
nary vein stenosis, cardiac tamponade, anaphylactic reaction, pericarditis 
and death).  
Secondary end-
points 
 Freedom from documented atrial arrhythmia at a whole standard 
ECG recording (regardless of the estimated duration) or 
Holter/CIED (≥24 hours) at 12 and 24 months and 5 years (after 3 
months blanking period), on or off antiarrhythmic drugs (AAD). 
 Freedom from documented persistent atrial arrhythmia at 12 and 
24 months and 5 years (after 3 months blanking period), on or off 
AAD. 
 Freedom from DC cardioverted atrial arrhythmia at 12 and 24 
months and 5 years (after 3 months blanking period), on or off 
AAD. 
 Number of DC-cardioversions (after 3 months blanking period) and 
sustained atrial arrhythmia episodes at 12 and 24 months and 5 
years. 
 Freedom from accepted chronic atrial fibrillation at 12 and 24 
months and 5 years. 
 Freedom from re-ablation procedure at 12 and 24 months and 5 
years. 
 
Change in AFEQT score between baseline and 24 months and be-
tween baseline and 5 years. 
Number of patients 
180  
Follow up time 
12 months (primary endpoint) and 24 months and 60 months 
 
 

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Department of Cardiology 
Aarhus University Hospital 
 
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1.0 Background 
Atrial fibrillation (AF) is the most common sustained arrhythmia in adults with a lifetime risk 
of approximately 30%. AF significantly increases the risk of stroke, is associated with in-
creased overall mortality and may impair quality of life.1 Treatments to effectively eliminate 
AF and maintain sinus rhythm may not only improve quality of life, but may even reduce 
mortality.2,3 
In patients with paroxysmal AF (PAF), AF has been found to be triggered by frequent ectopic 
atrial activity emerging from the pulmonary veins (PVs). Pulmonary vein isolation (PVI) has 
been developed to isolate the ectopic activity from initiating AF. PVI has proven efficient in 
patients with PAF with 1-year success rates up to 90%.  
In patients with persistent AF (PsAF), data on a PV trigger-based initiation is not so clear, 
and the 1-year efficacy of pulmonary vein isolation only in this population is reported be-
tween 50-70% and significant lower as compared with patients with PAF. Furthermore, in 
patients having recurrence after PVI, a large proportion of patients with PsAF have isolated 
pulmonary veins at re-ablation. This indicates that patients with PsAF that have recurrence 
after PVI might benefit from ablation outside the pulmonary veins.  
For some time, it has been assumed that in patients with PsAF there may be additive effect 
to PVI, by targeting the atrial substrate responsible for AF maintenance.4 However, the best 
method to characterize and target this so-called “substrate” remains elusive. The most com-
monly employed techniques for targeting the substrate used in the past were the creation of 
linear lesions across critical structures of the left atrium (LA), ablation of complex fraction-
ated electrograms (CFAE), and targeting areas of low voltage detected by multipolar elec-
troanatomical mapping.   
The STAR AF II study showed that addition of either linear ablation or ablation of CFAE to 
PVI for PsAF did not offer any additional benefit over PVI alone.5 There was no significant 
difference in the results of the three strategies in terms of freedom from AF or any atrial 
arrhythmia. In fact, there seemed to be a weak trend towards better outcome with PVI alone. 
However, the STAR- AF II study included only de-novo procedures and in patients returning 
for re-do procedures, only 20% had isolated veins, indicating that durable block across the 
lines was achieved in a minority of this cohort.5  
With updated approaches and technologies, including introduction of pulsed-field ablation, 
the efficiency of creating durable isolation of PVs has significantly increased over the last 
years. While PVI alone still remains the standard for the first ablation in patients with PsAF, 
the PVs are found to be isolated in a higher proportion of patients referred for re-do ablation. 
This shows that in these patients, PVI alone is not sufficient and revive the relevance of 
investigating the significance of targeting substrate outside PVs. 
The VENUS study demonstrated the benefit of vein of Marshall (VOM) ethanol ablation in 
de novo ablation of PsAF.6 Furthermore, preliminary results of the Marshall plan study sug-
gest the benefit of VOM ethanol ablation in combination with block of mitral and tricuspid 
isthmus and dome line, also in de novo ablation of PsAF. Whether this strategy improves 
outcome in patients with PsAF undergoing re-ablation where the need for extrapulmonary 
ablation might be higher has not been tested in a randomized study We aim to investigate, 

Re-AF study 
Department of Cardiology 
Aarhus University Hospital 
 
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if the addition of VOM ethanol ablation in combination with block of mitral and tricuspid isth-
muses and dome line to PV re-isolation will improve the results of re-ablation of PsAF.  
2.0 Aim 
The aim of this study is to investigate whether the addition of VOM ethanol ablation in com-
bination with block of mitral and tricuspid isthmuses and dome line to standard PV re-isola-
tion improves quality of life as compared to PV re-isolation alone, in patients who undergo 
re-ablation for PsAF.  
2.1 Hypothesis 
Addition of VOM ethanol ablation in combination with block of mitral and tricuspid isthmuses 
and dome line to standard PV re-isolation improves quality of life and reduces recurrence of 
atrial arrhythmias as compared to standard PV re-isolation alone in patients undergoing re-
ablation for PsAF.   
3.0 Methods 
3.1 Study conduct  
This is an investigator-initiated and investigator-sponsored multi-center trial at the Depart-
ment of Cardiology Aarhus University Hospital, Department of Cardiology, Karolinska Uni-
versity Hospital, Stockholm and Department of Cardiology, Leiden University Medical Cen-
ter. The study is conducted in accordance with the protocol, applicable regulatory require-
ments and the ethical principles of the Declaration of Helsinki. 
3.2 Study design  
This study is a prospective, patient and assessor blinded, 1:1 randomized superiority trial.  
Consecutive patients referred for re-ablation of symptomatic PsAF after previous PVI will be 
included. All preoperative procedures will be conducted according to the department’s 
standard operational procedures for AF ablation. In all patients, an electro anatomical map 
(CARTO™, Biosense Webster, Diamond Bar, CA, or EnSite X™, Abbott Laboratories, Ab-
bott Park, IL) of the LA with a multipolar mapping catheter (PENTARAY™ or OCTARAY™, 
Biosense Webster, Diamond Bar, CA, or Advisor™ HD Grid, Abbott Laboratories, Abbott 
Park, IL) will be constructed and reconnection of PVs will be assessed in sinus rhythm. If 
reconnection is present, re-PVI will be performed and confirmed with the multipolar mapping 
catheter. Patients in atrial fibrillation will undergo cardioversion to sinus rhythm prior to map-
ping. After mapping and confirming isolation of the PVs, patients will be randomized using 
the Redcap Database software to intervention or control. The intervention group will undergo 
VOM ethanol ablation including supplementary LA and coronary sinus ablation, if needed to 
achieve mitral isthmus block plus creation of dome line and cavotricuspid isthmus (CTI) 
block according to section 3.7. VOM ablation, mitral and CTI ablation and dome line will not 
be performed in control group and patients in control group will undergo no further ablation.  
The energy source used will be radiofrequency ablation or pulsed field ablation, at the dis-
cretion of the physician. However, radiofrequency should be preferred near coronary arter-
ies. For dome line, focal PFA is preferred. All post-procedural work-up and follow-up will be 
the same for both randomization groups and assessment of outcomes will be performed by 
personnel blinded to randomization. 

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Department of Cardiology 
Aarhus University Hospital 
 
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3.3 Definition of persistent atrial fibrillation 
A standard 12-lead ECG recording or a single-lead ECG tracing of ≥30 s showing heart 
rhythm with no discernible repeating P waves and irregular RR intervals (when atrioventric-
ular conduction is not impaired) is diagnostic of clinical AF.1 A high-rate episode detected 
by implanted device or wearable monitor, may be diagnostic of AF after inspection of the 
stored electrogram.  
An episode of AF, continuously sustained beyond 7 days, including episodes terminated by 
cardioversion (drugs or electrical cardioversion) after ≥7 days, is regarded as PsAF. 
3.4 Eligibility criteria 
Consecutive patients are included on the following criteria: 
3.4.1 Inclusion criteria:  
 
 Previous pulmonary vein isolation for atrial fibrillation 
 Indication for catheter ablation with at least two episodes of symptomatic PsAF dur-
ing the last 12 months during  
 Previous PVI for atrial fibrillation 
 Age  18 years 
 Expected survival   12 months  
 Able to provide informed consent 
 
3.4.2 Exclusion criteria:  
 Previous extrapulmonary atrial ablation other than cavotricuspid isthmus line, roof- 
or dome-line or posterior wall isolation/ablation 
 Atypical atrial flutter in addition to atrial fibrillation 
 Atrial fibrillation secondary to a transient abnormality 
 Uncontrolled hypertension 
 Acute coronary syndrome, cardiac surgery, or TIA/stroke within the last 3 months 
 Planned cardiac surgery within 1 year 
 Dialysis or severe renal failure 
 Active substance or alcohol abuse (>14 units/week) 
 
 
3.4 Power calculation 
Assuming a 10-point difference in the change in AFEQT score between the intervention 
and control group with 90% power and a 5% significance level, assuming a standard devi-
ation of 20 points (typical standard deviation for QoL in studies using the AFEQT question-
naire), a sample size of 168 patients will be required. With expected dropout during follow-
up, 180 patients will be randomized in the study. The study will also be powered for the 
secondary endpoint (90% power and a 5% significance level, assuming 75% freedom of 
persistent atrial arrhythmia in the intervention group and 50% in the control group, a sam-
ple size of 148 patients is required). 
 

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Department of Cardiology 
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3.5 Study endpoints 
Primary endpoint: 
 Change in AFEQT score between baseline and 12 months. 
 
Secondary endpoints:  
 Freedom from documented atrial arrhythmia at a whole standard ECG recording (re-
gardless of the estimated duration) or Holter/CIED (≥24 hours) at 12 and 24 months 
and 5 years (after 3 months blanking period), on or off antiarrhythmic drugs (AAD). 
 Freedom from documented persistent atrial arrhythmia at 12 and 24 months and 5 
years (after 3 months blanking period), on or off AAD. 
 Freedom from DC cardioverted atrial arrhythmia at 12 and 24 months and 5 years 
(after 3 months blanking period), on or off AAD. 
 Number of DC-cardioversions (after 3 months blanking period) and sustained atrial 
arrhythmia episodes at 12 and 24 months and 5 years. 
 Freedom from accepted chronic atrial fibrillation at 12 and 24 months and 5 years. 
 Freedom from re-ablation procedure at 12 and 24 months and 5 years. 
 Change in AFEQT score between baseline and 24 months and between baseline and 
5 years. 
 
Primary safety endpoints: 
 Peri- or postprocedural complications (vascular complication needing intervention, 
conduction disturbances requiring a pacemaker, gastroesophageal fistula, phrenic 
nerve damage, stroke or systemic embolism, PV stenosis, cardiac tamponade, ana-
phylactic reaction, pericarditis and death).  
3.6 Supplementary study parameters 
The following baseline parameters will be collected from patients in the study: age, sex, 
body mass index, CHA2DS2-VASc score, AF history and duration, details of previous abla-
tion procedures, history of heart disease and previos treatment of heart disease and other 
related conditions as diabetes, hypertension, thyroid dysfunction, cardiovascular risk fac-
tors, failed and current anti-arrhythmic drugs, left ventricular ejection fraction, LA dimensions 
and volume index, mitral insufficiency grade (0-4), mitral stenosis grade (0-4), any other 
structural heart disease, INR values at the day of ablation, ACT levels during ablation, total 
amount of units of heparin infused, total cholesterol, HDL- and LDL-cholesterol, triglycerides, 
TSH.  
Procedural parameters as procedure duration, fluoroscopy time and dose will be collected 
as well. 
In addition, the result from standard follow-up at 12 months after the procedure including 
recurrence of atrial fibrillation, ECG, medication and symptoms as well as EHRA score and 
quality of life assessment (AFEQT) will be analyzed to compare long term outcome. 
 

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3.7 Strategy for the procedure 
According to standard clinical protocol and in accordance with international recommenda-
tions, after obtaining venous vascular access, a 10-polar catheter is placed in the coronary 
sinus and one transseptal puncture is performed. After the placement of a steerable sheath 
(Agilis™, Abbott, Abbott Park, IL), a multipolar mapping catheter PENTARAY™ or OC-
TARAY™ (Biosense Webster, Diamond Bar, CA, US) or Advisor™ HD Grid (Abbott, Abbott 
Park, IL) will be deployed in the LA. 
The procedure will subsequently consist of two phases: 
1: Mapping and randomization in the study 
 A voltage map of the LA during atrial pacing will be created. Patients in AF will 
be cardioverted first. Reconnected PVs will be re-isolated.  
 Then pts will be randomized. 
 
2: Intervention 
 
Control group: 
 Programmed atrial stimulation (4 extra stimuli (ES) at 350 ms baseline 
cycle length (CL), with simultaneous decrement of all four ES down to 
refractory period). If AFL or AF will not be induced with programmed 
atrial stimulation, then burst pacing (5 s bursts with 10 ms decrement 
between bursts, starting from CL 300 ms down to 180 ms), will be per-
formed. Mean CL of AF will be measured in left and right appendage. If 
AFL is induced, this is mapped using a combination of activation and 
entrainment mapping, but will not be ablated. Patients will be cardio-
verted to sinus rhythm and no additional ablation will be performed.  
Intervention group:  
 CTI block and VOM ethanol injection will be performed. Mitral isthmus 
block will be completed with endocardial and, if necessary, epicardial 
ablation in coronary sinus followed by dome line. Order of the ablation 
lines will be performed at the discretion of the physician. Programmed 
atrial stimulation will be performed as described above, and if AFL or 
AF will not be induced, then burst pacing will be performed as described 
above. In case of AF, mean CL will be measured in left and right ap-
pendage. No additional mapping or ablation of AF will be performed 
and the patient will be cardioverted. If AFL is induced, this is mapped 
and ablated using a combination of activation and entrainment map-
ping. Afterwards, induction will be performed again until AFL is not in-
ducible anymore. If AF will be induced two times in a row, AF will be 
cardioverted and the procedure ended. The procedure is ended earlier 
on the discretion of the operator or if induced AFL is judged non-clinical. 
All the lines will be checked at the end of procedure for bidirectional 
block according to the respective institution’s standard and a waiting 
time after the last ablation at a line will be 30 minutes.  

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3.10 Follow up 
After 3 months, a clinical follow-up is performed including ECG. If persistent AF or AFL is 
present, the patient will be cardioverted. AAD (class I and III) will be discontinued at 3 
months of follow-up if the patient is in sinus rhythm and discouraged during follow-up. In 
case of recurrences during follow-up, AAD will be initiated at the discretion of the physician.   
In the case of recurrent symptomatic atrial arrhythmia, the patient will be offered a new pro-
cedure. However, repeat procedures during the first twelve months will be avoided. In case 
that a re-procedure cannot be avoided, QOL measurements will be taken immediately be-
fore the procedure.  
After 12 months, a 5 days Holter recording in addition to an ECG and quality of life assess-
ment (AFEQT) is included. The medical history is reviewed to identify documented AF or 
AFL as indication of recurrence.  
After 24 months and 5 years, an ECG and quality of life assessment (AFEQT) is included. 
All follow-up will be performed by personnel blinded for the randomization. 
 
3.11 Statistics and data analysis plan  
All analysis will be conducted according to the intention-to-treat (ITT) principle (as a superi-
ority analysis) and difference in the primary endpoint AFECT score from baseline to 12 
months follow-up will be analysed using student t-test and presented with mean difference 
and 95% CI.  
For secondary endpoints, continuous variables will be evaluated by independent sample 
student’s t-test, discrete variables will be evaluated by Chi-square statistics (or fisher’s exact 
test if applicable), time dependent endpoints will be displayed with Kaplan-Maier curves and 
compared using a two-sided log-rank test.  
Demographic and baseline data will be compared between the two groups. Variables will be 
expressed as mean ± SD, and percentage. If differences exist between groups in baseline 
data, these variables will be used in final comparison between the two treatment groups as 
potential confounders.  
Procedure related parameters (fluoroscopy-, procedure- and ablation times) will be com-
pared between the two groups and expressed as mean ± SD, and percentage.  
 
3.12 Randomization 
The patients will be randomly assigned in a 1:1 ratio to intervention or control group after 
the initial mapping and PVI using the Redcap web-based database system. Apart from the 
investigator, all health care professionals and the patient will be blinded to the allocation. 

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4.0 RECRUITMENT OF PARTICIPANTS 
4.1 Consent to participate 
As normal clinical praxis, all patients scheduled for AF ablation are seen in the out-patient-
clinic 4-6 weeks before the procedure where the medical history is clarified, CT scanning is 
done and the patients receive information about the procedure. Patients referred to redo 
procedures for AF (approximately 200 patients) are screened to identify candidates that 
comply to the inclusion and exclusion criteria. Following information in patient record is used 
for this screening: age, frequency, symptomatology and duration of AF episodes during the 
last year, previous ablation procedures and concomitant diseases. This information will be 
found in the medical record from the last year. This information will be passed-on to the 
project. Potential candidates will be approached by a study dedicated nurse and under un-
disturbed conditions, she will provide oral and written information about the study. Written 
consent form may be signed at this time, later during the day or on the day of the procedure. 
This ensures that the patient has sufficient time (at least >48 hours) to consider participation 
and to discuss this with relatives if desired. Another meeting with participation of relatives 
can be arranged. At any time, participants may withdraw their consent without having to give 
a reason for this. Patients who decide not to join the study will receive treatment according 
to current best clinical practice.  
Normally, inclusion of 180 patients in the three participating centers will last less than a year.  
4.2 Insurance 
Participants are covered by, at the participating center, standard insurance in case they 
experience serious adverse events. The options to complain and apply for compensation 
will be explained in the written information about the study. 
5.0 ETHICAL ASPECTS 
5.1 Risks and inconvenience 
The duration of the procedure is expected to be approximately 60 minutes longer in the 
intervention group compared to the control group. However, the majority of complications 
related to AF ablation, are related to the transseptal puncture, which will be performed in 
both groups.  
In the intervention group, more widespread ablation will take place, potentially increasing 
the risk of severe complications such as tamponade, stroke, coronary artery lesion, esoph-
ageal fistula, phrenic nerve palsy, and conduction disturbances requiring a pacemaker. 
These complications are rare and reported after less than <0.1% of procedures, including 
procedures with extensive ablation for PsAF.7 VOM ethanol ablation carries an increase in 
the risk of pericarditis and a very small risk (0.4%) of anaphylactic reaction.   
 

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5.2 Beneficial effects 
On an individual level, the participants will be followed more closely than after a standard 
procedure, accordingly reaction to adverse events and recurrence may be prompt. As hy-
pothesized, the participants in the intervention group may have lower risk of arrhythmias 
after the procedure compared to standard treatment. 
On a population basis, future patients undergoing redo ablation for PsAF, may benefit from 
results of this study. 
6.0 BIO BANK 
No biological material will be removed from the patient and nothing will be stored for further 
research during this study. 
7.0 Data collection, processing, and storage 
7.1 Monitoring 
The investigator will permit trial-related monitoring, audits, IRB/IEC review, and regulatory 
inspection(s), providing direct access to source data/documents. 
 
7.2 Data Collection 
Electronic Case Report Forms (eCRFs) will be developed to capture the information outlined 
in this protocol. Data from these eCRFs will be used in the analysis of study results. Modifi-
cation of the eCRFs will only be made if deemed necessary by the primary investigators. 
All data related to the study will be stored in a REDCAP database administered by Aarhus 
University in accordance with local regulations including “Databeskyttelsesforordningen” 
and “Databeskyttelsesloven” and only after approval by local data storage authorities. The 
data are stored in Denmark and are thereby subjected to Danish legislation.  Only the main 
investigator and one study nurse will have access to the data. Data will be kept until 10 years 
after completion of the study. 
 
7.3 Data reporting 
The study nurse and primary investigator are responsible for recording all data from the 
study on the eCRFs based on source-documented hospital chart reviews.  
 
7.4 Source Documentation 
Data entered on to the eCRFs will be taken from source documentation, such as hospital 
procedure reports, admission and discharge summaries, and other hospital or physician of-
fice/clinic documents. For some information unique to this study, no standard hospital or 
office document exists. Therefore, a worksheet will be developed for this purpose, signed 
by the primary investigator and serve as the source document for those data parameters. 
These source documents will be used for monitoring the eCRFs. Electronic patient records 

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will be considered as source documents in general. All eCRFs will undergo manual inspec-
tion for omitted data, gross data inconsistencies, and timelines of reporting.  
 
7.5 Data update 
Regulations require that physicians maintain information in the subject’s medical records, 
which corroborate data collected on the eCRFs. In order to comply with these regulatory 
requirements, at minimum, the following is a list of information that should be maintained. 
Medical history/physical condition of the study subject before inclusion in the study sufficient 
to verify inclusion criteria (if not already present). Adverse events reported and their resolu-
tion, including supporting documents such as discharge summaries, EP lab reports, ECGs, 
lab results. Study subject’s condition upon completion of or withdrawal from the study.  
 
7.5 Access to patient related information 
Only after patient have signed consent to participate in the study, information as described 
in section 3.5 and 3.6 (Study parameters/endpoints) will be acquired from the medical rec-
ord. This means that the main investigator will directly access the medical record to obtain 
the information needed to complete the study as described.  
 
7.6 Final Data Analyses 
All exported datasets for analyses will undergo a final data verification procedure. Once all 
critical data are monitored and locked, the final analyses of study data will be performed 
blinded to the treatment allocation. 
8.0 QUALITY ASSURANCE 
Periodic monitoring of the study will be performed to ensure that all subjects have signed 
Informed Consent Form, that randomization procedures are being followed, and that source 
document verification is conducted. 
The physician should not deviate from the protocol without the prior notification and approval 
from the Principal Investigator, except when unavoidable due to a medical emergency.  
Periodic analyses of eCRFs will be performed in order to examine the expected distributions 
of data, and to identify outliers for possible data mistakes. 
9.0 ECONOMICS 
This is an investigator-initiated study and funding will be applied for in public and private 
funds to cover expenses of extra monitoring and study personnel including nurses and study 
coordinators. No companies or other external funders are involved in the conduction of the 
study or will be granted access to any of the stored information in the study. Patients and 
investigators will not receive any compensation for participating in the study. Study nurse 

Re-AF study 
Department of Cardiology 
Aarhus University Hospital 
 16 
will participate in patient inclusion and follow-up. The investigators do not have any econom-
ical association with subjects interested in the results of this study. 
10.0 ADDITIONAL STUDY INFORMATION 
The study is initiated by Dept. of Cardiology, Aarhus University Hospital and electrophysiol-
ogists at Department of Cardiology, Karolinska University Hospital, Stockholm and Depart-
ment of Cardiology, Leiden University Medical Center will be involved in the study. Patients 
are covered by hospital liability insurance.  
11.0 PUBLICATION POLICY 
Before start, the study will be registered at ClinicalTrials.gov. After finalization of the project, 
a publication in an international peer-reviewed journal is intended regardless of whether the 
results are positive, negative or inconclusive. 
12.0 LITERATURE 
 
1. 
Hindricks G, Potpara T, Dagres N, et al. 2020 ESC Guidelines for the diagnosis and management of 
atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic 
Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the 
European Society of Cardiology (ESC) Developed with the special contribution of the European 
Heart Rhythm Association (EHRA) of the ESC. Eur Heart J 2021;42(5):373-498. (In eng). DOI: 
10.1093/eurheartj/ehaa612. 
2. 
Packer DL, Mark DB, Robb RA, et al. Effect of Catheter Ablation vs Antiarrhythmic Drug Therapy on 
Mortality, Stroke, Bleeding, and Cardiac Arrest Among Patients With Atrial Fibrillation: The CABANA 
Randomized Clinical Trial. Jama 2019;321(13):1261-1274. (In eng). DOI: 10.1001/jama.2019.0693. 
3. 
Marrouche NF, Brachmann J, Andresen D, et al. Catheter Ablation for Atrial Fibrillation with Heart 
Failure. N Engl J Med 2018;378(5):417-427. (In eng). DOI: 10.1056/NEJMoa1707855. 
4. 
Verma A, Macle L. Persistent Atrial Fibrillation Ablation: Where Do We Go From Here? Can J Cardiol 
2018;34(11):1471-1481. (In eng). DOI: 10.1016/j.cjca.2018.08.008. 
5. 
Verma A, Jiang CY, Betts TR, et al. Approaches to catheter ablation for persistent atrial fibrillation. N 
Engl J Med 2015;372(19):1812-22. (In eng). DOI: 10.1056/NEJMoa1408288. 
6. 
Valderrábano M, Peterson LE, Swarup V, et al. Effect of Catheter Ablation With Vein of Marshall 
Ethanol Infusion vs Catheter Ablation Alone on Persistent Atrial Fibrillation: The VENUS 
Randomized Clinical Trial. Jama 2020;324(16):1620-1628. (In eng). DOI: 10.1001/jama.2020.16195. 
7. 
Arbelo E, Brugada J, Blomström-Lundqvist C, et al. Contemporary management of patients 
undergoing atrial fibrillation ablation: in-hospital and 1-year follow-up findings from the ESC-EHRA 
atrial fibrillation ablation long-term registry. Eur Heart J 2017;38(17):1303-1316. (In eng). DOI: 
10.1093/eurheartj/ehw564.