Completeness of Linear or Fractionated Electrogram Ablation in Addition to Pulmonary Vein Isolation on Ablation Outcome

HomeCirculation: Arrhythmia and ElectrophysiologyVol. 14, No. 9Completeness of Linear or Fractionated Electrogram Ablation in Addition to Pulmonary Vein Isolation on Ablation Outcome Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessLetterPDF/EPUBCompleteness of Linear or Fractionated Electrogram Ablation in Addition to Pulmonary Vein Isolation on Ablation OutcomeA Substudy of the STAR AF II Trial Paula Sanchez-Somonte, MD, Chen-yang Jiang, MD, Timothy R Betts, MD, Jian Chen, MD, Roberto Mantovan, MD, PhD, Laurent Macle, MD, Carlos A Morillo, MD, Wilhelm Haverkamp, MD, PhD, Rukshen Weerasooriya, MD, Jean-Paul Albenque, MD, Stefano Nardi, MD, Endrj Menardi, MD, Paul Novak, MD, Prashanthan Sanders, MBBS and Atul Verma, MD Paula Sanchez-SomontePaula Sanchez-Somonte https://orcid.org/0000-0001-5642-8100 Southlake Regional Health Centre, Newmarket, Canada (P.S.-S., A.V.). , Chen-yang JiangChen-yang Jiang https://orcid.org/0000-0002-0199-3353 Department of Cardiology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, China (C.-y.J.). , Timothy R BettsTimothy R Betts https://orcid.org/0000-0001-9063-9905 Department of Cardiology, Oxford University Hospitals, John Radcliffe Hospital, Oxford, United Kingdom (T.R.B.). , Jian ChenJian Chen https://orcid.org/0000-0003-3008-5706 Department of Cardiology, Haukeland University Hospital, University of Bergen, Norway (J.C.). , Roberto MantovanRoberto Mantovan https://orcid.org/0000-0002-9970-7924 Department of Cardiology, Ospedale S. Maria di Ca' Foncelli, Treviso, Italy (R.M.). , Laurent MacleLaurent Macle https://orcid.org/0000-0002-3328-5239 Department of Cardiology, Montreal Heart Institute (L.M.). , Carlos A MorilloCarlos A Morillo https://orcid.org/0000-0002-8739-2099 Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Canada (C.A.M.). , Wilhelm HaverkampWilhelm Haverkamp https://orcid.org/0000-0002-6183-2519 Department of Cardiology, Charité Campus Virchow-Klinikum, Berlin, Germany (W.H.). , Rukshen WeerasooriyaRukshen Weerasooriya Department of Cardiology, Hollywood Private Hospital, Nedlands, Western Australia, Australia, University of Western Australia, Crawley (R.W.). , Jean-Paul AlbenqueJean-Paul Albenque Department de Rythmologie, Clinique Pasteur Toulouse, France (J.-P.A.). , Stefano NardiStefano Nardi Department of Cardiology, Pineta Grande Hospital, Castel Volturno (S.N.). , Endrj MenardiEndrj Menardi https://orcid.org/0000-0003-2184-3093 Department of Cardiology, Ospedale Santa Croce e Carle, Cuneo, Italy (E.M.). , Paul NovakPaul Novak https://orcid.org/0000-0002-8792-7938 Department of Cardiology, Royal Jubilee Hospital, Victoria, Canada (P.N.). , Prashanthan SandersPrashanthan Sanders https://orcid.org/0000-0003-3803-8429 Department of Cardiology, Centre for Heart Rhythm Disorders, University of Adelaide & Royal Adelaide Hospital, Australia (P.S.). and Atul VermaAtul Verma Correspondence to: Atul Verma, MD, Southlake Regional Health Centre, 602-581 Davis Drive, Newmarket, Ontario, Canada, L3Y 2P6. Email E-mail Address: [email protected] https://orcid.org/0000-0002-1020-9727 Southlake Regional Health Centre, Newmarket, Canada (P.S.-S., A.V.). Originally published7 Sep 2021https://doi.org/10.1161/CIRCEP.121.010146Circulation: Arrhythmia and Electrophysiology. 2021;14Although pulmonary vein isolation (PVI) is the cornerstone of treatment for paroxysmal atrial fibrillation (AF), success rates are substantially lower in patients with persistent AF.1 Despite ongoing advances in the field, the ablation of persistent AF remains challenging, and the optimum ablation strategy is still unknown.To improve outcomes for persistent AF, more extensive ablation based on linear lesions or complex fractionated electrograms (CFE) ablation in addition to PVI have been proposed.The STAR AF II (Substrate and Trigger Ablation for Reduction of Atrial Fibrillation 2) was a large multicenter, randomized trial that randomized patients to PVI alone, PVI plus CFE, or PVI plus linear ablation (roof line and mitral line).2 The study failed to show any additional benefit of additional substrate ablation (CFE or lines) in addition to PVI. However, complete block of linear ablations or total elimination of CFE was not achieved in all patients in the adjuvant ablation arms, and this could explain why these additive ablation strategies did not improve outcome. We sought to determine whether completeness of adjuvant linear or CFE ablation affected the outcome of these additive ablation strategies when combined with PVI. The study was approved by an institutional review committee and subjects gave informed consent.In STAR AF II, patients (n=549) were randomized 1:4:4 to PVI alone, PVI plus lines, and PVI plus CFE. Patients were followed for 18 months with a visit, ECG, and 24-hour Holter at 3, 6, 9, 12, and 18 months, plus weekly and symptoms-driven transtelephonic monitoring. After the blanking period, recurrence was defined as any documented atrial arrhythmia >30 s after one procedure on or off antiarrhythmics. Of the 243 patients in the PVI plus lines group who received both mitral and roof lines, bidirectional block across both lines was achieved in 179 (74%) but was not achieved in 64 (26%). The mitral line was the most common line which was not blocked (61/64). At 18 months follow-up, AF recurrence occurred in 107 of 179 patients (59.8%) with complete conduction block across both lines and in 40 of 64 patients (62.5%) without complete block (P=0.89; Figure). Even after 2 procedures, AF recurred in 51.9% of patients with complete linear block and 46% of patients without complete block (P=0.09). Of the 207 patients in the PVI plus CFE group who actually underwent CFE ablation, 188 (91%) had elimination of all CFE sites, whereas all CFE were not eliminated in 19 (9%). At 18 months follow-up, AF recurrence occurred in 117 of 188 patients (62.2%) with all the CFE ablated and in 11 of 19 patients (57.9%) without all CFE ablated (P=0.47; Figure). After 2 procedures, AF recurrence occurred in 56.7% of patients with all CFE ablated and 68.0% of patients without all CFE ablated (P=0.29). The percentage of patients who received a second ablation procedure was 22% in the PVI group, 26% in the CFE plus PVI group, and 33% in PVI plus lines (P=0.10). The percentage of patients with ≥1 PVs recovered was 77% in the PVI group, 86% in the CFE+PVI, and 83% in the PVI+lines (P=0.51).Download figureDownload PowerPointFigure. Freedom from atrial arrhythmia. The graph shows Kaplan-Meier estimates of freedom from documented atrial arrhythmia >30 s after a single procedure with or without the use of antiarrhythmic medications. There were no significant differences between groups: linear block achieved vs not achieved (upper) and all the complex fractionated electrograms (CFE) ablated vs not all CFE ablated (lower).In this substudy, we demonstrate that outcomes of patients with complete linear block and without complete linear block did not differ. Similarly, outcomes for patients with all CFE regions successfully ablated were similar to without all the CFE successfully ablated. At the time of a repeat procedure, >80% in both groups (PVI+lines and PVI+CFE) had at least one pulmonary vein (PV) recovered. This suggests that regardless of how well empirical linear or CFE ablation is performed, it still does not influence AF recurrence with similar outcomes to PVI alone. Furthermore, the finding that most patients in all groups had at least one PV recovered emphasizes the need for a good, wide antral PV isolation as the cornerstone of persistent AF ablation. These findings are supported by the CHASE AF trial (Catheter Ablation of Persistent Atrial Fibrillation: Pulmonary Vein Isolation Versus Defragmentation) which showed that PVI combined with both linear and CFE ablation did not result in less AF recurrence compared with PVI alone even after more than one procedure.3 A meta-analysis of many trials examining the impact of both linear and CFE ablation also concluded that these adjuvant strategies did not improve outcome over PVI alone1 even after multiple procedures which suggests that lines and CFE will not improve outcome no matter how well or often they are ablated. Other strategies have been proposed in addition to PVI to improve outcome in ablation of persistent AF. These include ablation of AF sources4 and posterior wall isolation.5 However, these strategies have also had mixed results. Ultimately, comparative clinical trials between the various strategies and technologies will be needed to determine which, in fact, is the best approach for persistent AF.Sources of FundingDr Sánchez-Somonte is supported by a grant from the Fundación Alfonso Martin Escudero (Madrid, Spain). The original STAR AF 2 trial (Substrate and Trigger Ablation for Reduction of Atrial Fibrillation 2) was supported by St Jude Medical International.Disclosures The data that support the findings of this study are available from the corresponding author upon reasonable request. Dr Verma reports grants from Abbott, Bayer, Biosense Webster, Biotronik, Medtronic, and Medlumics; advisory boards for Biosense Webster, Kardium, Medtronic, Medlumics, and Thermedical; clinical trials for Adagio Medical, Biosense Webster, Galaxy Medical, Kardium, Medtronic, and Thermedical. The other authors report no conflicts.FootnotesFor Sources of Funding and Disclosures, see page 899.Correspondence to: Atul Verma, MD, Southlake Regional Health Centre, 602-581 Davis Drive, Newmarket, Ontario, Canada, L3Y 2P6. Email atul.[email protected]caReferences1. Clarnette JA, Brooks AG, Mahajan R, Elliott AD, Twomey DJ, Pathak RK, Kumar S, Munawar DA, Young GD, Kalman JM, et al.. Outcomes of persistent and long-standing persistent atrial fibrillation ablation: a systematic review and meta-analysis.Europace. 2018; 20:f366–f376. doi: 10.1093/europace/eux297CrossrefMedlineGoogle Scholar2. Verma A, Jiang CY, Betts TR, Chen J, Deisenhofer I, Mantovan R, Macle L, Morillo CA, Haverkamp W, Weerasooriya R, et al.; STAR AF II Investigators. Approaches to catheter ablation for persistent atrial fibrillation.N Engl J Med. 2015; 372:1812–1822. doi: 10.1056/NEJMoa1408288CrossrefMedlineGoogle Scholar3. Vogler J, Willems S, Sultan A, Schreiber D, Lüker J, Servatius H, Schäffer B, Moser J, Hoffmann BA, Steven D. Pulmonary vein isolation versus defragmentation: the CHASE-AF clinical trial.J Am Coll Cardiol. 2015; 66:2743–2752. doi: 10.1016/j.jacc.2015.09.088CrossrefMedlineGoogle Scholar4. Willems S, Verma A, Betts TR, Murray S, Neuzil P, Ince H, Steven D, Sultan A, Heck PM, Hall MC, et al.. Targeting nonpulmonary vein sources in persistent atrial fibrillation identified by noncontact charge density mapping: UNCOVER AF trial.Circ Arrhythm Electrophysiol. 2019; 12:e007233. doi: 10.1161/CIRCEP.119.007233LinkGoogle Scholar5. Lee JM, Shim J, Park J, Yu HT, Kim TH, Park JK, Uhm JS, Kim JB, Joung B, Lee MH, et al.; POBI-AF Investigators. The electrical isolation of the left atrial posterior wall in catheter ablation of persistent atrial fibrillation.JACC Clin Electrophysiol. 2019; 5:1253–1261. doi: 10.1016/j.jacep.2019.08.021CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails September 2021Vol 14, Issue 9Article InformationMetrics Download: 239 © 2021 American Heart Association, Inc.https://doi.org/10.1161/CIRCEP.121.010146PMID: 34488431 Originally publishedSeptember 7, 2021 Keywordspatientsinformed consentpulmonary veincatheter ablationatrial fibrillationrecurrencePDF download SubjectsArrhythmiasElectrophysiologyAtrial Fibrillation