Pulmonary Vein Isolation With Optimized Linear Ablation vs Pulmonary Vein Isolation Alone for Persistent AF
Authors: Sang Caihua , Liu Qiang , Lai Yiwei , Xia Shijun , Jiang Ruhong , Li Songnan , Guo Qi , Li Qifan , Gao Mingyang , Guo Xueyuan , Huang Lihong , Liu Nian , Jiang Chenxi , Zuo Song , Liu Xiaoxia , Li Mengmeng , Ge Weili , Song Shangming , Chen Lianghua , Xie Shuanglun , Zou Jiangang , Chen Ke , Liu Xiangfei , Hu Hesheng , Wang Xinhua , Zhang Jinlin , Wang Zhaojun , Wang Chi , He Liu , Jiang Chao , Tang Ribo , Zhou Ning , Wang Yunlong , Long Deyong , Du Xin , Jiang Chenyang , Macle Laurent , Dong Jianzeng , Ma Changsheng ,   PROMPT-AF investigators, Wang Wei , Zhao Xin , Li Changyi , Liang Zhuo , Li Xu , Kong Xiangyi , Dai Wenli , Wang Yufeng , Yu Lu , Ding Xueyan , Cheng Hui , Lin Jianwei , Zhang Pei , Sun Yaxun , Hou Xiaofeng , Wang Yao , Xue Yumei , Bai Rong , Du Jing 
Published: November 2024

ImportanceSuccess rates of pulmonary vein isolation (PVI) are modest for persistent atrial fibrillation (AF). Additional linear ablation beyond PVI has not been proved superior to PVI alone in randomized trials. Ethanol infusion of the vein of Marshall (EIVOM) facilitates ablation at the mitral isthmus and may lead to improved effectiveness of a linear ablation strategy.ObjectiveTo determine whether linear ablation with radiofrequency energy combined with EIVOM added to PVI improves sinus rhythm maintenance compared with PVI alone in patients with persistent AF.Design, Setting, and ParticipantsThe PROMPT-AF trial is an investigator-initiated, multicenter, open-label, randomized trial involving 12 tertiary hospitals in China. A total of 498 patients aged 18 to 80 years, with AF persisting for more than 3 months, undergoing first-time AF ablation, were enrolled and randomized from August 27, 2021, to July 16, 2023.InterventionsPatients were randomized to undergo PVI alone or PVI plus EIVOM and linear ablation (intervention). The latter group first underwent EIVOM, followed by PVI and linear ablation of the left atrial roof, mitral isthmus, and cavotricuspid isthmus.Main Outcomes and MeasuresThe primary end point was freedom from any documented atrial arrhythmias lasting more than 30 seconds, without the use of antiarrhythmic drugs within 12 months. Secondary outcomes included freedom from atrial arrhythmia recurrence, AF, atrial arrhythmia recurrence after multiple procedures, and documented atrial tachycardia or atrial flutter with or without antiarrhythmic drugs; AF burden; and improvement in quality of life. Patients were monitored with wearable single-lead electrocardiographic (ECG) patches, worn for 24 hours a week, supplemented by symptom-triggered ECGs and Holter monitoring.ResultsAmong 498 randomized patients, 495 (99.4%) were included in the primary analysis (mean age, 61.1 years [SD, 9.7] years, 361 male [72.9%]). After 12 months, 174 of 246 patients (70.7%) assigned to undergo PVI plus EIVOM and linear ablation and 153 of 249 patients (61.5%) assigned to undergo PVI alone remained free from atrial arrhythmias without taking antiarrhythmic drugs (hazard ratio, 0.73; 95% CI, 0.54-0.99, P = .045). The intervention effect was consistent across all prespecified subgroups. The comparison of secondary outcomes did not demonstrate significant results.ConclusionAmong patients with persistent AF, linear ablation combined with EIVOM in addition to PVI significantly improved freedom from atrial arrhythmias within 12 months compared with PVI alone.Trial RegistrationClinicalTrials.gov Identifier: NCT04497376