Biatrial linear ablation in sustained nonpermanent AF: Results of the substrate modification with ablation and antiarrhythmic drugs in nonpermanent atrial fibrillation (SMAN-PAF) trial. Electrogram-guided substrate ablation with or without pulmonary vein isolation in patients with persistent atrial fibrillation. Substrate modification combined with pulmonary vein isolation improves outcome of catheter ablation in patients with persistent atrial fibrillation: a prospective randomized comparison. Does electrogram guided substrate ablation add to the success of pulmonary vein isolation in patients with paroxysmal atrial fibrillation? A prospective, randomized study. Substrate and Trigger Ablation for Reduction of Atrial Fibrillation (STAR AF): a randomized, multicentre, international trial† Pulmonary Vein Isolation Versus Defragmentation: The CHASE-AF Clinical Trial. Incidence and significance of early recurrences associated with different ablation strategies for AF: a STAR-AF substudy. Impact of Stepwise Ablation on the Biatrial Substrate in Patients With Persistent Atrial Fibrillation and Heart Failure Ganglionated plexus ablation vs linear ablation in patients undergoing pulmonary vein isolation for persistent/long-standing persistent atrial fibrillation: a randomized comparison. Long-term comparison of cryoballoon and radiofrequency ablation of paroxysmal atrial fibrillation: a propensity score matched analysis. Noninvasive Assessment of Atrial Substrate Change after Wide Area Circumferential Ablation: A Comparison with Segmental Pulmonary Vein Isolation Long-Term Clinical Results of 2 Different Ablation Strategies in Patients With Paroxysmal and Persistent Atrial Fibrillation The difference in autonomic denervation and its effect on atrial fibrillation recurrence between the standard segmental and circumferential pulmonary vein isolation techniques. Circumferential Pulmonary Vein Ablation With Additional Linear Ablation Results in an Increased Incidence of Left Atrial Flutter Compared With Segmental Pulmonary Vein Isolation as an Initial Approach to Ablation of Paroxysmal Atrial Fibrillation Pulmonary vein triggers play an important role in the initiation of atrial flutter: Initial results from the prospective randomized Atrial Fibrillation Ablation in Atrial Flutter (Triple A) trial. Pulmonary venous isolation by antral ablation with a large cryoballoon for treatment of paroxysmal and persistent atrial fibrillation: medium-term outcomes and non-randomised comparison with pulmonary venous isolation by radiofrequency ablation Real-time contact force sensing for pulmonary vein isolation in the setting of paroxysmal atrial fibrillation: procedural and 1-year results. Surgical vs. transcatheter pulmonary vein isolation as first invasive treatment in patients with atrial fibrillation: a matched group comparison. Circumferential pulmonary vein isolation with the cryoballoon technique results from a prospective 3-center study. One-year follow-up after irrigated multi-electrode radiofrequency ablation of persistent atrial fibrillation. Efficacy of additional ablation of complex fractionated atrial electrograms for catheter ablation of nonparoxysmal atrial fibrillation. Ablation of atrial fibrillation with cryoballoon or duty-cycled radiofrequency pulmonary vein ablation catheter: a randomized controlled study comparing the clinical outcome and safety; the AF-COR study. Evaluation of linear lesions in the left and right atrium in ablation of long-standing atrial fibrillation.
BACKGROUND More advanced atrial fibrillation ( AF ) is associated with lower success rates after pulmonary vein isolation ( PVI ) , and the optimal ablation strategy is uncertain . OBJECTIVES To assess the impact of additional linear ablation ( lines ) compared to PVI alone . METHODS In this multicenter r and omized controlled trial , 122 patients ( mean age 61.9 ± 10.5 years ; left atrial diameter 43 ± 6 mm ) with persistent AF ( PeAF ) or sustained ( > 12 hours ) paroxysmal AF ( SusPAF ) with risk factors for atrial substrate were included and followed up for 12 months . Patients were r and omized to  PVI-only or PVI + lines ( left atrial roof line , mitral isthmus line , and tricuspid isthmus line ) group . Holter monitoring was performed at 3 , 6 , and 12 months and according to symptoms . The primary outcome was atrial tachyarrhythmia recurrence lasting ≥30 seconds . RESULTS Baseline characteristics were comparable between groups ; 61 % had PeAF and 39 % SusPAF . Successful PVI was achieved for 98 % of pulmonary veins , and bidirectional block was obtained in 90 % of lines . The primary end point occurred in 38 % of the PVI + lines group and 32 % of the PVI-only group ( P = .50 ) , which was consistent in both PeAF ( 36 % vs 28 % ; P = .45 ) and SusPAF ( 42 % vs 39 % ; P = .86 ) . Compared with the PVI-only group , the PVI + lines group had higher procedure duration ( 209 ± 52 minutes vs 172 ± 44 minutes ; P < .001 ) , ablation time ( 4352 ± 1084 seconds vs 2503 ± 1061 seconds ; P < .001 ) , and radiation exposure ( Dose-area product 3992 ± 6496 Gy·cm(2 ) vs 2106 ± 1679 Gy·cm(2 ) ; P = .03 ) . Quality of life ( disease-specific Atrial Fibrillation Effect on Quality of Life question naire and mental component scale of the Short Form 36 Health Survey ) improved significantly during the study but did not differ between groups . CONCLUSION Adding lines to wide antral PVI in substrate-based AF requires significantly more ablation , increases procedure duration and radiation dose , but provides no additional clinical benefit AIMS Ablation of complex fractionated atrial electrograms ( CFAEs ) is a new approach for the treatment of atrial fibrillation ( AF ) . The purpose of the study was to assess the efficacy of CFAE ablation as a st and -alone strategy in patients with persistent AF and to compare it with a combined approach of CFAE ablation and pulmonary vein isolation ( PVI ) . METHODS AND RESULTS The study included 77 consecutive patients with persistent AF who underwent radiofrequency ( RF ) ablation of CFAE as a sole ablation procedure ( CFAE group , n = 23 patients ) or a combined approach of CFAE ablation and PVI ( CFAE plus PVI group , n = 54 patients ) . Procedures were guided by three-dimensional mapping systems . After the procedure , AF recurrences were evaluated with 7-day Holter recordings at 1 , 3 , and 6 months and every 6 months thereafter . Treatment failure was defined as > or=1 AF episode lasting > 30 s on Holter recordings during follow-up . After a mean follow-up time of 13 + /- 10 months , 2 of 23 patients ( 9 % ) with CFAE ablation and 22 of 54 patients ( 41 % ) with CFAE plus PVI were in sinus rhythm after a single ablation procedure without anti-arrhythmic medication ( P = 0.008 ) . CONCLUSION Ablation of CFAE as a st and -alone ablation strategy seems insufficient for the treatment of patients with persistent AF . Pulmonary vein isolation plus CFAE ablation significantly increases the mid-term success rate AIMS To investigate the effectiveness of additional substrate modification ( SM ) by left atrial ( LA ) linear lesions as compared with pulmonary vein isolation ( PVI ) alone in patients with persistent atrial fibrillation ( AF ) in a prospect i ve r and omized study . Percutaneous PVI has evolved as an accepted treatment for paroxysmal AF but seemed to be less effective in patients with persistent AF . The benefit of PVI alone and additional linear lesions has not been vali date d in a r and omized study so far . METHODS AND RESULTS Sixty-two patients with persistent AF ( median duration 7 , range 1 - 18 months ) were r and omly assigned to either PVI alone ( n = 30 ) or additional SM ( n = 32 ) consisting of a roof line connecting both left superior and right superior PV and LA isthmus ablation between left inferior PV and mitral annulus . Procedures including SM were performed using a three-dimensional mapping system ( EnSite NavX , St Jude Medical , St Paul , MN , USA ) . Anti-arrhythmic drugs were discontinued within 8 weeks after ablation in both groups . Follow-up included daily trans-telephonic ECG transmitted irrespective of the patient 's symptoms . PVI was successful in 98 % of all targeted veins in both groups . Additional SM did not increase fluoroscopy time ( 72.1+/-18.7 vs. 72.9+/-17.3 min , P=0.92 ) because of the use of three-dimensional navigation in the PVI+SM group . AF recurrences within the first 4 weeks following ablation were more common after PVI alone ( 77 % ) than additional SM ( 44 % , P=0.002 ) . After a follow-up time of 487 ( 429 - 570 ) days , only 20 % of patients undergoing st and alone PVI  remained in sinus rhythm when compared with 69 % following PVI combined with SM ( P=0.0001 ) . Two patients assigned to PVI+SM experienced procedure-related complications ( cardiac tamponade and minor stroke ) which resolved without sequelae . CONCLUSION PVI alone is insufficient in the treatment of persistent AF . However , additional left linear lesions increase the success rate significantly . Early AF-relapses are associated with a negative outcome after PVI alone but not following additional SM INTRODUCTION Pulmonary vein isolation ( PVI ) is an established treatment for paroxysmal atrial fibrillation ( AF ) . The ablation of complex fractionated atrial electrograms ( CFAE ) has emerged as a novel treatment approach . We sought to evaluate the additional effect of CFAE ablation to PVI in paroxysmal AF . METHODS AND RESULTS Ninety-eight patients with paroxysmal AF ( 57 + /- 10 years , 74 male ) were r and omized to the PVI ( n = 48 ) or PVI + CFAE group ( n = 50 ) . After PVI , CFAE ablation was performed in patients with inducible AF in the PVI + CFAE group . The primary endpoint was combined objective ( 7-day Holter ECG ) and subjective ( symptoms ) freedom of atrial tachyarrhythmia 3 months after ablation . Long-term follow-up ( 19 + /- 8 months ) was available in 94 of 98 patients . CFAE ablation was performed in 30 of 50 patients of the PVI + CFAE group . After 3 months , 36 of 48 patients ( 75 % ) in the PVI group and 38 of 50 patients ( 76 % ) in the PVI + CFAE group were in stable sinus rhythm ( P = NS ) . During long-term follow-up ( 19 + /- 8 months ) , 34 of 46 patients ( 74 % ) in the PVI group and 40 of 48 patients ( 83 % ) in the PVI + CFAE group were in sinus rhythm ( P = 0.08 ) . In a subgroup analysis , a significantly better long-term outcome was achieved if inducible AF after PVI had been treated by additional CFAE ablation as compared with PVI only ( sinus rhythm in 25/28 patients ; 89 % vs 22/30 patients 73 % ; P = 0.003 ) . CONCLUSION In the intention-to-treat analysis , additional CFAE ablation did not improve the success rate of PVI in patients with paroxysmal AF . However , during long-term follow-up , patients with still inducible AF after PVI seemed to profit from additional CFAE ablation Aims This multicentre , r and omized trial compared three strategies of AF ablation : ablation of complex fractionated electrograms ( CFE ) alone , pulmonary vein isolation ( PVI ) alone , and combined PVI + CFE ablation , using st and ardized automated mapping software . Methods and results Patients with drug-refractory , high-burden paroxysmal ( episodes > 6 h , > 4 in 6 months ) or persistent atrial fibrillation ( AF ) were enrolled at eight centres . Patients ( n = 100 ) were r and omized to one of three arms . For CFE alone ( n = 34 ) , spontaneous/induced AF was mapped using vali date d , automated CFE software and all sites < 120 ms were ablated until AF termination/non-inducibility . For PVI ( n = 32 ) , all four PV antra were isolated and confirmed using a circular catheter . For PVI + CFE ( n = 34 ) , all four PV antra were isolated , followed by AF induction and ablation of all CFE sites until AF termination/non-inducibility . Patients were followed at 3 , 6 , and 12 months with a visit , ECG , 48 h Holter . Atrial fibrillation symptoms were confirmed by loop recording . Repeat procedures were allowed within the first 6 months . The primary endpoint was freedom from AF > 30 s at 1 year . Patients ( age 57 ± 10 years , LA size 42 ± 6 mm ) were 35 % persistent AF . In CFE , ablation terminated AF in 68 % . Only 0.4 PVs per patient were isolated as a result of CFE . In PVI , 94 % had all four PVs successfully isolated . In PVI + CFE , 94 % had all four PVs isolated , 76 % had inducible AF with additional CFE ablation , with 73 % termination of AF . There were significantly more repeat procedures in the CFE arm ( 47 % ) vs. PVI ( 31 % ) or PVI + CFE ( 15 % ) ( P = 0.01 ) . After one procedure , PVI + CFE had a significantly higher freedom from AF ( 74 % ) compared with PVI ( 48 % ) and CFE ( 29 % ) ( P = 0.004 ) . After two procedures , PVI + CFE still had the highest success ( 88 % ) compared with PVI ( 68 % ) and CFE ( 38 % ) ( P = 0.001 ) . Ninety-six percent of these patients were off anti-arrhythmics . Complications were two tamponades , no PV stenosis , and no mortality . Conclusion In high-burden paroxysmal/persistent AF , PVI + CFE has the highest freedom from AF vs. PVI or CFE alone after one or two procedures . Complex fractionated electrogram alone has the lowest one and two procedure success rates with a higher incidence of repeat procedures . Clinical Trials.gov identifier number NCT00367757 BACKGROUND Long-term success rates using ablation for persistent atrial fibrillation ( AF ) are disappointing and usually do not exceed 60 % . OBJECTIVES This study sought to compare arrhythmia-free survival between pulmonary vein isolation ( PVI ) and a stepwise approach ( full defrag ) consisting of PVI , ablation of complex fractionated electrograms , and additional linear ablation lines in the setting of atrial tachycardias ( AT ) in patients with persistent AF after PVI . METHODS From November 2010 to February 2013 , 205 patients ( 151 men ; 61.7 ± 10.2 years of age ) underwent de novo ablation for persistent AF . Subsequently , patients were prospect ively r and omized to either PVI alone ( n = 78 ) or full defrag ( n = 75 ) , with 52 patients not r and omized due to AF termination with the original PVI . The primary endpoint was recurrence of any AT after a blanking period of 3 months . RESULTS During the entire study , 241 ablations were performed ( mean : 1.59 in the PVI-alone group , 1.55 in the full-defrag group ) . With the stepwise approach , termination of AF occurred in 45 ( 60 % ) patients . However , arrhythmia-free survival did not differ whether patients underwent single or multiple procedures ( p = 0.468 ) . Procedure duration , fluoroscopy time , and radiofrequency duration were significantly longer in the full-defrag group ( all p < 0.001 ) . CONCLUSIONS A stepwise approach aim ed at AF termination does not seem to provide additional benefit over PVI alone in patients with persistent AF , but it is associated with significantly longer procedural and fluoroscopic duration as well as radiofrequency application time . ( The R and omized Catheter Ablation of Persist End Atrial Fibrillation Study [ CHASE-AF ] ; NCT01580124 ) BACKGROUND Early recurrences of atrial tachyarrhythmias ( ERAT ) are common after  atrial fibrillation ( AF ) ablation , and predict late recurrences ( LR ) . We sought to determine the impact of different ablation strategies on ERAT and LR . METHODS AND RESULTS The STAR-AF trial r and omized 100 patients with paroxysmal or persistent AF to ablation of complex fractionated electrograms ( CFAE ) alone , pulmonary vein isolation ( PVI ) alone , or combined PVI + CFAE .  Patients were followed for 12 months . ERAT was defined as any recurrence of AF , atrial tachycardia , or flutter ( AT/AFL ) > 30 seconds during the first 3 months of follow-up . LR was defined as any recurrence of AF/AT/AFL > 30 seconds 3 - 12 months post . Forty-nine patients experienced ERAT . The index ablation strategy was the only independent predictor of ERAT on multivariate analysis ( HR 2.24 PVI vs PVI + CFAE ; and HR 2.65 CFAE vs PVI + CFAE ) . Fifty-two patients experienced LR . The presence of ERAT ( HR 3.23 ) , the use of antiarrhythmic drug ( AAD ) in the first 3 months postablation ( HR 2.85 ) , and the index ablation strategy were independently associated with LR ( HR 3.42 PVI vs PVI + CFAE ; HR 4.72 CFAE vs PVI + CFAE ) . Thirty-five of 49 ( 71 % ) patients with ERAT and 17 ( 33 % ) of 51 patients without ERAT had LR ( P < 0.0001 ) . Among patients with ERAT , increased left atrium size ( HR 1.08 ) , the use of AAD in the first 3 months postablation ( HR 2.86 ) and the index ablation strategy were independently associated with LR ( HR 4.77 PVI vs PVI + CFAE ; HR 4.45 CFAE vs PVI + CFAE ) . CONCLUSION ERAT is common following AF ablation and is strongly associated with LR . Although CFAE ablation alone results in higher rates of early and LR , the addition of CFAE to PVI results in increased long-term success without an increase in ERAT Background —Ablation of persistent atrial fibrillation can be challenging , often involving not only pulmonary vein isolation ( PVI ) but also additional linear lesions and ablation of complex fractionated electrograms ( CFE ) . We examined the impact of stepwise ablation on a human model of advanced atrial substrate of persistent atrial fibrillation in heart failure . Methods and Results —In 30 patients with persistent atrial fibrillation and left ventricular ejection fraction ⩽35 % , high-density CFE maps were recorded biatrially at baseline , in the left atrium ( LA ) after PVI and linear lesions ( roof and mitral isthmus ) , and biatrially after LA CFE ablation . Surface area of CFE ( mean cycle length ⩽120 ms ) remote to PVI and linear lesions , defined as CFE area , was reduced after PVI ( 18.3±12.03 to 10.2±7.1 cm2 ; P<0.001 ) and again after linear lesions ( 7.7±6.5 cm2 ; P=0.006 ) . Complete mitral isthmus block predicted greater CFE reduction ( P=0.02 ) . Right atrial CFE area was reduced by LA ablation , from 25.9±14.1 to 12.9±11.8 cm2 ( P<0.001 ) . Estimated 1-year arrhythmia-free survival was 72 % after a single procedure . Incomplete linear lesion block was an independent predictor of arrhythmia recurrence ( hazard ratio , 4.69 ; 95 % confidence interval , 1.05–21.06 ; P=0.04 ) . Conclusions —Remote LA CFE area was progressively reduced following PVI and linear lesions , and LA ablation reduced right atrial CFE area . Reduction of CFE area at sites remote from ablation would suggest either regression of the advanced atrial substrate or that these CFE were functional phenomena . Nevertheless , in an advanced atrial fibrillation substrate , linear lesions after PVI diminished the target area for CFE ablation , and complete lesions result ed in a favorable clinical outcome BACKGROUND The optimal ablation technique for persistent and long-st and ing persistent atrial fibrillation ( AF ) is unclear . Both linear lesion ( LL ) and ganglionated plexus ( GP ) ablation have been used in addition to pulmonary vein isolation ( PVI ) , but no direct comparison of the 2 methods exists . OBJECTIVE The aim of this study is to assess the comparative safety and efficacy of 2 different ablation strategies-PVI+LL vs PVI+GP ablation -in patients with persistent or long-st and ing persistent AF . METHODS Two hundred sixty-four consecutive patients with persistent/long-st and ing persistent AF were r and omly assigned to 2 different ablation schemes : PVI+LL ( n = 132 ) and PVI+GP ( n = 132 ) ablation . Consistent sinus rhythm ( SR ) off antiarrhythmic drug was assessed after follow-up of at least 3 years with the use of an implanted monitoring device . RESULTS All procedural end points were acutely achieved . At 12 months after a single procedure , 47 % of the patients treated with PVI+LL were in SR compared to 54 % of the patients treated with PVI+GP ( P = .29 ) . At 3 years , 34 % of the patients with PVI+LL and 49 % of the patients with PVI+GP maintained SR ( P = .035 ) . Atrial flutter was more frequent in the PVI+LL group than in PVI+GP group ( 18 % vs 6 % ; P = .002 ) . After a second procedure in 78 patients of the PVI+LL group and 55 patients of the PVI+GP group , the long-term overall success rate was 52 % and 68 % , respectively ( P = .006 ) . CONCLUSIONS PVI+GP ablation confers superior clinical results with less ablation-related left atrial flutter and reduced AF recurrence compared to PVI+LL ablation at 3 years of follow-up BACKGROUND Although radiofrequency ( RF ) and cryoballoon ( CB ) based technologies for pulmonary vein isolation ( PVI ) have both individually been demonstrated to be effective and safe for the treatment of paroxysmal AF , head-to-head comparisons are lacking . The purpose of this study was to compare the outcome of cryoballoon versus radiofrequency ablation in patients with paroxysmal atrial fibrillation undergoing pulmonary vein isolation . METHODS Out of a prospect i ve registry of 327 patients undergoing PVI , 208 patients ( age 58±11 years , ejection fraction 59±6 % , left atrial size 39±6 mm ) with paroxysmal AF were identified . The presented data set was obtained by 1:1 propensity score matching and contained 142 patients undergoing CB-PVI or RF-PVI in conjunction with a 3D mapping system , respectively . We compared single procedure efficacy of the two methods using a Cox proportional hazards model . RESULTS After a mean follow-up of 28 months and a single procedure , AF recurred in 37 of 71 ( 52 % ) in the CB-PVI group and in 31 of 71 patients ( 44 % ) in the RF-PVI group ( HR [ 95 % CI]=1.19 [ 0.74 , 1.92 ] , p=0.48 ) . Recurrence of AF for PVI using solely the CB was observed in 23 of 51 ( 45 % ) patients and in 23 of 51 ( 45 % ) patients in the corresponding RF-PVI group ( HR [ 95 % CI]=0.93 [ 0.52 , 1.66 ] , p=0.81 ) . Complication rate was not different between the groups . CONCLUSION A propensity score matched comparison between CB-PVI and RF-PVI using a 3D-mapping system for AF ablation showed similar long-term success rates Background : The wide area circumferential ablation ( WACA ) approach to atrial fibrillation is thought to result in ‘ substrate modification ’ perhaps related to autonomic denervation . We examined this prospect ively by comparing WACA and segmental pulmonary vein isolation ( PVI ) using noninvasive surrogate markers Background — Data regarding the long-term efficacy of atrial fibrillation ( AF ) ablation are still lacking . Methods and Results —Two hundred four consecutive patients symptomatic for paroxysmal or persistent/permanent AF were r and omly assigned to 2 different ablation schemes : pulmonary vein isolation ( PVI ) and PVI plus left linear lesions ( LL ) . Primary end point was to assess the maintenance of sinus rhythm ( SR ) after procedures 1 and 2 in the absence of antiarrhythmic drugs in a long-term follow-up of at least 3 years . Paroxysmal AF — With a single procedure at 12-month follow-up , 46 % of patients treated with PVI maintained SR , whereas at 3-year follow-up , 29 % were in SR ; using the “ PVI plus LL ” at the 12-month follow-up , 57 % of patients were in SR , whereas at the 3-year follow-up , 53 % remained in SR . After a second procedure , the long-term overall success rate without antiarrhythmic drugs was 62 % with PVI and 85 % with PVI plus LL . Persistent/Permanent AF — With a single procedure at the 12-month follow-up , 27 % of patients treated with PVI were in SR , whereas at the 3-year follow-up , 19 % maintained SR ; using the PVI plus LL with a single procedure at the 12-month follow-up 45 % of patients were in SR , whereas at the 3-year follow-up , 41 % remained in SR . After a second procedure , the long-term overall success rate without antiarrhythmic drugs was 39 % with PVI and 75 % with PVI plus LL . Conclusions —A long-term follow-up of AF ablation shows that short-term results can not be considered permanent because AF recurrences are still present after the first year especially in patients who have had “ PVI ” strategy .  PVI isolation plus LL is superior to the PVI strategy in maintaining SR without antiarrhythmic drugs after procedures 1 and 2 both in paroxysmal and persistent AF AIMS This study examined the difference in autonomic modification ( AM ) and its effect on paroxysmal atrial fibrillation ( PAF ) recurrence between segmental pulmonary vein isolation ( S-PVI ) and circumferential PVI ( C-PVI ) . METHODS AND RESULTS Successful S-PVI or C-PVI with a basket catheter was achieved in 120 consecutive PAF patients . Serial 24 Holter-recordings were obtained before , immediately , and 1 , 3 , 6 , 12 months after the PVI to analyse the heart rate variability ( HRV ) .  Nineteen patients were excluded from analysis because of additional ablation for recurrent PAF after successful PVI . Among the residual 101 patients , 33 had PAF recurrences ( S-PVI = 44.0 % , C-PVI = 21.6 % ) at 1 year of follow-up . The root mean square of successive differences and high-frequency power reflecting parasympathetic nervous activity were significantly lower in patients with and without PAF recurrences after C-PVI and patients without PAF recurrences after S-PVI than patients with PAF recurrences after S-PVI ( P < 0.005 - 0.0001 ) . However , there were no significant differences in any HRV parameters in the immediate aftermath of PVI among the patients without PAF recurrences after S-PVI and those with and without PAF recurrences after C-PVI . CONCLUSION Although additional radiofrequency ablation for AM may be recommended after S-PVI to reduce PAF recurrences , it should be carefully determined after C-PVI Background —There has been growing concern that linear ablation is associated with an increased risk of iatrogenic arrhythmias in patients undergoing ablation for atrial fibrillation ( AF ) . Therefore , we compared circumferential pulmonary vein ablation plus left atrial linear ablation ( CPVA+LALA ) with segmental pulmonary vein isolation (PVI)in  patients with paroxysmal AF . Methods and Results —Sixty-six consecutive patients with paroxysmal AF were prospect ively r and omly assigned to receive PVI versus CPVA+LALA ( consisting of encircling lesions around the pulmonary veins ) , a roof line , and a mitral isthmus line with documentation of bidirectional mitral isthmus block . All patients were seen at 1 , 3 , 6 , and every 12 months after ablation , with 14-day continuous ECG monitoring every 6 months . At 16.4±6.3 months after 1 ablation procedure , 19 patients ( 58 % ) remained free of atrial arrhythmias after PVI versus 17 patients ( 51 % ) after CPVA+LALA ( P=0.62 ) . After PVI , 14 patients had recurrent paroxysmal AF , whereas after CPVA+LALA , 8 patients had recurrent AF , 6 had atypical left atrial flutter ( LAFL ) , and 2 had both AF and LAFL ( P=0.32 between PVI versus CPVA+LALA for AF but P=0.002 for LAFL ) . Twenty-eight patients ( 85 % ) remained arrhythmia-free after 1.3±0.5 PVI procedures versus 28 patients ( 85 % ) after 1.4±0.6 CPVA+LALA procedures ( P = NS ) . Fluoroscopy time was longer after CPVA+LALA versus PVI ( 91 versus 73 minutes , P=0.04 ) . Conclusions —As an initial ablation approach in patients with paroxysmal AF  , more LAFL occurred after CPVA+LALA and fluoroscopy times were longer compared with segmental PVI BACKGROUND The incidence of atrial fibrillation ( AF ) after ablation of a cavotricuspid isthmus (CTI)-dependent atrial flutter ( AFL ) is high . OBJECTIVE The purpose of this study was to test the hypothesis that AFL and AF may be initiated by pulmonary vein triggers . This prospect i ve r and omized trial tested the efficacy of a st and alone pulmonary vein isolation ( PVI ) in patients with AFL but without AF . METHODS Patients with AFL but without documented AF were r and omly assigned to 1 of 3 treatment groups : ( 1 ) antiarrhythmic drugs ( AAD ) , ( 2 ) CTI ablation , or ( 3 ) circumferential PVI . The primary end-point was defined as any recurrent atrial tachyarrhythmia and the secondary end-point as recurrence of AFL . In case of tachyarrhythmia recurrence in the PVI group , a second PVI was performed to close gaps in the ablation lines . RESULTS Of the 60 patients , 17 were r and omized to AAD , 23 to CTI ablation , and 20 to PVI . During follow-up of 1.42 ± 0.83 years , 14 of 17 patients ( 82.4 % ) in the AAD group , 14 of 23 patients ( 60.9 % ) in the CTI group , and 2 of 20 patients ( 10 % ) in the PVI group reached the primary end-point ( P < .001 ) after a mean of 1.4 PVI procedures per patient . AFL reoccurred in 9 patients ( 52.9.% ) in the AAD group , in 2 patients ( 8.7 % ) in the CTI group , and after a single PVI in 3 patients ( 15 % ) in the PVI group ( P = .003 ) . After closure of gaps , 1 patient ( 5 % ) in the PVI group presented with recurrent AFL . CONCLUSION Pulmonary vein triggers play an important role in AFL . PVI can prevent the recurrence of AFL , even without CTI ablation Background To prevent  atrial fibrillation ( AF ) recurrence after catheter ablation , pulmonary venous isolation ( PVI ) at an antral level is more effective than segmental ostial ablation . Cryoablation around the pulmonary venous ( PV ) ostia for AF therapy is potentially safer compared to radiofrequency ablation ( RFA ) . The aim of this study was to investigate the efficacy of a strategy using a large cryoablation balloon to perform antral cryoablation with ‘ touch-up ’ ostial cryoablation for PVI in patients with paroxysmal and persistent AF . Methods Paroxysmal and persistent AF patients undergoing their first left atrial ablation were recruited . After cryoballoon therapy , each PV was assessed for isolation and if necessary , treated with focal ostial cryoablation until PVI was achieved . Follow-up with Holter monitoring was performed . Clinical outcomes of the cryoablation protocol were compared , with consecutive patients undergoing PVI by RFA . Results 124 consecutive patients underwent cryoablation . 77 % of paroxysmal and 48 % of persistent AF subjects were free from AF at 12 months after a single procedure . Over the same time period , 53 consecutive paroxysmal AF subjects underwent PVI with RFA and at 12 months , 72 % were free from AF at 12 months ( p = NS ) . There were too few persistent AF subjects ( n=8 ) undergoing solely PVI by RFA as a comparison group . Procedural and fluoroscopic times during cryoablation were significantly shorter than RFA . Conclusions PV isolation can be achieved in less than 2 h by a simple cryoablation protocol with excellent results after a single intervention , particularly for paroxysmal AF INTRODUCTION The additional benefit of contact force ( CF ) technology during pulmonary vein isolation ( PVI ) for paroxysmal atrial fibrillation ( AF ) to improve mid-term clinical outcome is unclear . METHODS AND RESULTS Eligible patients with symptomatic paroxysmal AF were enrolled in this prospect i ve trial , comparing circular antral catheter ablation ( guided by Carto 3 System , Biosense Webster ) using either a new open-irrigated CF catheter ( SmartTouch Thermocool , Biosense Webster ) ( CF group ) or a non-CF open-irrigated catheter ( EZ Steer Thermocool , Biosense Webster ) ( control group ) . Overall , 30 patients were enrolled in each group , with a st and ardized 12-month follow-up , free of antiarrhythmic therapy . Demographic , cardiovascular and anatomic characteristics were similar in both groups . Though complete PVI was eventually achieved in all cases in both groups , success using an exclusive anatomic approach was 80.0 % in CF group versus 36.7 % in control group ( P < 0.0001 ) . CF use was associated with significant reductions in fluoroscopy exposure ( P < 0.01 ) and radiofrequency time ( P = 0.01 ) . The incidence rates of AF recurrence were 10.5 % ( 95 % CI , 1.38 - 22.4 ) in the CF group , and 35.9 % ( 95 % CI , 12.4 - 59.4 ) in the control group ( log rank test , P = 0.04 ) . After adjustment on potential confounders , the use of CF catheter was found to be associated with a lower AF recurrence ( OR 0.18 , 95 % CI 0.04 - 0.94 , P = 0.04 ) . CONCLUSION Our findings suggest a potential benefit of real-time CF sensing technology , in reducing AF recurrence during the first year after PVI AIMS Pulmonary vein isolation ( PVI ) can be considered for treatment of symptomatic atrial fibrillation ( AF ) . Nowadays , in addition to transcatheter ablation , thoracoscopic surgical PVI is available . The aim of this study is to compare clinical outcome of surgical with transcatheter PVI as first invasive treatment strategy of AF . METHODS AND RESULTS From June 2009 to November 2011 , 33 patients underwent minimally invasive surgical PVI , and were matched ( 1:2 fashion ) retrospectively according to age , sex , and AF type , with 66 patients who underwent transcatheter PVI .  Success was defined as freedom from atrial arrhythmias on 24 h Holter monitoring without use of anti-arrhythmic drugs ( AADs ) at 1 year . Mean age was 52 ± 10 years , 82 % were male . Paroxysmal AF was present in 76 patients ( 77 % ) , persistent AF in 23 ( 23 % ) patients . None underwent prior ablations , and failed on 1.2 ± 0.6 AADs . At 12 months , complete freedom from atrial arrhythmias without AADs in the surgical PVI group was 88 % compared with 41 % in the transcatheter PVI group ( P < 0.001 ) . Freedom from atrial arrhythmias with AADs was 91 vs. 62 % , in the surgical vs. transcatheter PVI group , respectively ( P = 0.002 ) . Complications occurred in seven ( 21 % ) surgical PVI patients , and three ( 5 % ) transcatheter PVI patients ( P = 0.015 ) . CONCLUSION In present matched study comparing a surgical with transcatheter PVI treatment strategy in symptomatic AF patients failed on AADs , but without prior ablations , a surgical PVI strategy was more effective to prevent recurrence of atrial arrhythmias , than a transcatheter PVI treatment strategy . However , complications were more frequent with surgical PVI OBJECTIVES The purpose of this study was to investigate the efficacy safety of the novel cryoballoon device ( A rct ic Front , Cryocath , Quebec , Canada ) . BACKGROUND Antral pulmonary vein ( PV ) ablation with radiofrequency energy is widely used as a strategy for catheter ablation of paroxysmal atrial fibrillation ( PAF ) . A novel double lumen cryoballoon catheter was design ed for circumferential pulmonary vein isolation ( PVI ) with the cryoablation technique . METHODS We consecutively enrolled 346 patients with symptomatic , drug refractory paroxysmal ( n = 293 ) or persistent ( n = 53 ) atrial fibrillation ( AF ) . In all patients , PVI of all targeted PVs was the therapeutic aim . The primary end points of this nonr and omized study were : 1 ) acute isolation rate of targeted PV ; and 2 ) first electrocardiogram-documented recurrence of AF . The secondary end point was occurrence of PV stenosis or atrio-esophageal fistula . RESULTS The 1,360 of 1,403 PVs ( 97 % ) were targeted with balloons or balloons in combination with the use of Freezor Max ( Cryocath ) . We found that ablation with the cryoballoon result ed in maintenance of sinus rhythm in 74 % of patients with PAF and 42 % of patients with persistent AF . No PV narrowing occurred . The most frequent complication was right phrenic nerve palsy observed during cryoballoon ablation at the right superior PV . CONCLUSIONS Pulmonary vein isolation with a new cryoballoon technique is feasible . Sinus rhythm can be maintained in the majority of patients with PAF by circumferential PVI using a cryoballoon ablation system . Cryoablation was less effective in patients with persistent AF than in patients with PAF AIMS Irrigated multi-electrode ablation ( IMEA ) is a novel tool to perform pulmonary vein isolation ( PVI ) . The aim was to compare IMEA with point-by-point radiofrequency ( RF ) ablation in patients with persistent atrial fibrillation ( AF ) undergoing PVI . METHODS AND RESULTS Forty-nine patients ( age 60 ± 9 years , 82 % male ) were studied . In 24 patients , the IMEA catheter was used in conjunction with an electroanatomic mapping system . Twenty-five patients undergoing RF point-by-point ablation ( RF-PVI ) served as a control group . Validation of PVI based on the IMEA catheter was performed using a st and ard circular mapping catheter . Ninety-two of 94 pulmonary veins ( PVs ) ( 98 % ) were isolated using IMEA alone . Procedure time was 125 ± 23 min in the IMEA group and 127 ± 31 min in the RF-PVI group ( P = 0.79 ) . Fluoroscopy time was 12.2 ( 11 - 16.1 ) min with IMEA compared with 5.2 ( 4.1 - 9.3 ) min in the RF-PVI group ( P < 0.001 ) . Net ablation time was 11.8 ( 10.2 - 15.4 ) min in the IMEA group compared with 33.6 ( 30.3 - 40.1 ) min in the RF-PVI group ( P < 0.001 ) . Of 94 PVs presumed to be isolated after IMEA ablation , validation using a st and ard circular mapping catheter showed persistent PV potentials in 33 PVs ( 35 % ) , requiring additional IMEA ablation . At 12 months , 16 of 24 patients ( 67 % ) in the IMEA group compared with 17 of 25 patients ( 68 % ) in RF-PVI group were free from AF ( P > 0.99 ) . CONCLUSION With similar total procedure duration , IMEA-PVI was associated with shorter net ablation time and longer fluoroscopy time . Irrigated multi-electrode ablation recordings were not sufficient to confirm isolation in 35 % of PVs . Single-procedure efficacy after 12 months was similar between the two groups BACKGROUND The efficacy of ablation of complex fractionated atrial electrograms ( CFEs ) in the single ablation procedure for nonparoxysmal atrial fibrillation ( AF ) patients is not well demonstrated . The aim of this study was to compare the ablation strategies of pulmonary vein isolation ( PVI ) plus linear ablation with and without additional ablation ofCFEs in these patients . METHODS Consecutive 60 patients ( 49 + /- 11 years old , 50 male , 10 female ) with nonparoxysmal AF underwent catheter ablation guided by a NavX mapping system .  A stepwise approach included a circumferential PVI and left atrial ( LA ) linear ablation followed by either the additional ablation of continuous CFEs in the LA/coronary sinus ( the first 30 patients ) or not ( the second 30 patients ) , detected by an automatic algorithm . RESULTS There was no difference in the baseline characteristics between the two groups . Complete PVI eliminated some continuous CFEs and altered the distribution of CFEs . Following PVI and linear ablation , the remaining continuous CFEs were identified in 7.9 + /-10 % mapping sites of the LA and CS , and were ablated successfully with a procedural AF termination rate of 53 % . With a follow-up of 19 + /-11 months , a Kaplan-Meier analysis showed that the patients with additional ablation of the CFEs had a higher rate of sinus rhythm maintenance . Multivariate analysis showed the single procedure success could be predicted by the procedural AF termination and the additional ablation of continuous CFEs in the LA/CS . CONCLUSIONS Ablation of continuous CFEs after PVI and LA linear ablation had a better long-term efficacy based on the results of single-ablation procedure AIMS The urge to facilitate the atrial fibrillation ( AF ) ablation procedure has led to the development of new ablation catheters specifically design ed as ' one-shot tools ' for pulmonary vein isolation ( PVI ) . The purpose of this study was to compare the efficacy , safety , and procedure times for two such catheters using different energy sources . METHODS AND RESULTS One hundred and ten patients , referred for ablation of paroxysmal or persistent AF , were r and omized to treatment with either the cryoballoon or the circular multipolar duty-cycled radiofrequency-based pulmonary vein ablation catheter ( PVAC ) .  Complete PVI was achieved in 98 vs. 93 % patients in the cryoballoon and PVAC group , respectively , with complication rates of 8 vs. 2 % ( P = 0.2 ) . Complete freedom from AF , without antiarrhythmic drugs , after one single ablation procedure was seen in 46 % in the cryoballoon vs. 34 % after 12 months ( P = 0.2 ) . Procedure times were comparable , but fluoroscopy time was shorter for the cryoballoon ( 32 ± 16 min ) than for the PVAC procedures ( 47 ± 17 min ) ( P < 0.001 ) . A significant improvement of quality of life ( QoL ) and arrhythmia-related symptoms was seen in both groups after ablation . CONCLUSION Both catheters proved comparably effective and safe in achieving acute PVI , apart from the shorter fluoroscopy times achieved with the cryoballoon . At follow-up , there was no statistically significant difference between the groups regarding freedom from AF and clinical success . The QoL increased to the same levels as for the general Swedish population in both groups BACKGROUND This r and omized prospect i ve study compared three ablation strategies in patients with long-st and ing persistent atrial fibrillation ( LPeAF ) . It also explored the best procedural endpoint from among the following : circumferential pulmonary vein isolation ( PVI ) + left atrial ( LA ) linear lesions ( roofline , mitral isthmus ) + complex fractionated atrial electrogram ( CFAE ) ablation , PVI + LA linear lesions + cavotricuspid isthmus ( CTI ) ablation + CFAE ablation , and PVI + CFAE ablation . METHODS AND RESULTS A total of 210 patients with LPeAF referred for catheter ablation were enrolled and r and omized into three ablation groups . The patients in group A ( n = 70 ) underwent PVI followed by LA linear and CFAE ablation ; in 93 % of patients the primary endpoint was achieved ( five patients with incomplete linear lesions ) . Of the 70 patients in group B who were subjected to PVI followed by LA linear , CFAE , and CTI ablations , in 94 % of patients the primary endpoint was achieved ( four patients with incomplete linear lesions ) . All patients in group C ( n = 70 ) successfully underwent PVI and CFAE ablation . Direct current cardioversion was performed upon PVI , CFAE elimination , and completion of linear lesions . Patients were followed-up for atrial tachyarrhythmia recurrence for at least 24 months . After a single ablation procedure , group C ( 36 % ) exhibited the lowest success compared with group A ( 54 % ) and group B ( 51 % ) ( P = 0.06 ) . At the mean follow-up of 32 ± 9 months after the final ablation procedure , 53 patients ( 76 % ) in group A , 53 ( 76 % ) in group B , and 41 ( 59 % ) in group C were in sinus rhythm without antiarrhythmic drugs ( P = 0.03 ) . CONCLUSIONS In LPeAF , linear lesions in the LA help improve outcome of ablation , additional CTI ablation does not
A PVI-only strategy in PeAF patients with a low prevalence of structural heart disease using contemporary technology yields excellent outcomes comparable to those for paroxysmal AF ablation
BACKGROUND Early studies demonstrated relatively low success rates for pulmonary vein isolation ( PVI ) alone in patients with persistent atrial fibrillation ( PeAF ) .
However , the advent of new technologies and the observation that additional substrate ablation does not improve outcomes have created a new focus on PVI alone for treatment of PeAF .
OBJECTIVE The purpose of this study was to systematic ally review the recent medical literature to determine current medium-term outcomes when a PVI-only approach is used for PeAF .