Pulmonary vein isolation combined with a new protocol of linear ablation to treat persistent atrial fibrillation: a prospective cohort with 1 year follow-up
Authors: Castrejon Castrejon S , Martinez Cossiani M M C , Guido Lopez L G L , Jauregui Abularach M J A , Sanchez Somonte P S S , Merino Fuentes D M F , Sanz Verdejo B S V , Handayani A H , Martinez Maldonado M E M M , Gonzalez Davia R G D , Cobarro Galvez L C G , Moreno Gomez J R M G , Merino J L M L 
Published: May 2024

Abstract

Background
The clinical value of ablation strategies beyond pulmonary vein isolation (PVI) in patients with persistent atrial fibrillation (perFA) is not clearly established and the optimal strategy to cure perFA remains a challenge due to the high recurrence rate after PVI alone (up to 50% of patients during 1-year follow-up).

Purpose
To determine the additional therapeutic value of a new design of linear ablation in the left atrium (LA) added to PVI in patients with perFA.

Methods
In this prospective study consecutive patients with perFA were included and underwent PVI combined with a predefined homogeneous protocol of linear ablation in the LA: anterolateral line from the mitral annulus to the left superior pulmonary vein around the left atrial appendage, anteroseptal line and posterior wall isolation. Patients were followed during 12 months after ablation with daily 30 s single-lead ECG obtained with mobile applications. The main endpoint was the incidence of recurrences, defined as any documented, sustained (&gt;30 s) episodes of atrial arrhythmia that occurred after a 3 months blanking period. Antiarrhythmic drugs were avoided after the blanking period.

Results
59 patients were included (61 [IQR 53-69] years old, 76% male sex). Acutely successful PVI was achieved in all patients and the linear ablation protocol was performed in 52 (89,7%) patients. The linea ablation protocol was not completed in 6 patients due to the following reasons: repetitive AF triggering from the same PV in 2 patients, induction and successful focal ablation of left atrial flutter in 1 patient, respiratory failure in 1 patient with severe obstructive lung disease and excessively prolonged procedure time in 2 patients. 58 patients completed the 12 months follow-up period and 1 patient was lost due to end-stage heart failure. The survival free of atrial arrhythmia recurrences was 69.1% [95%CI 55.1-79.5] (Figure). No patient had recurrences of perAF (&gt;7 days continuous AF). 9 (53%) patients had at least 1 episode of self-limited paroxysmal AF. In these patients the average paroxysmal AF burden during the follow-up was 24 hours/year [IQR 9-24 hours/year]. In another 8 (47%) patients the recurrent arrhythmia was atypical left atrial flutter exclusively The incidence of procedure-related complications was 6,9%: 1 pericardial bleeding, 1 acute pulmonary edema, 1 splenic infarction and 1 stroke); no patient died during the study period.

Conclusions
A combined strategy of PVI plus the specific linear ablation protocol used in this study is associated with a low rate of atrial arrhythmia recurrences and total absence of persistent AF after ablation. A randomized multicenter clinical trial is ongoing to validate these results.Ablation strategy.Kaplan-Meier curve: recurrences