Multiple procedure outcomes for nonparoxysmal atrial fibrillation: Left atrial posterior wall isolation versus stepwise ablation

To compare multiple-procedure catheter ablation outcomes of a stepwise approach versus left atrial posterior wall isolation (LA PWI) in patients undergoing nonparoxysmal atrial fibrillation (NPAF) ablation.Unfavorable outcomes for stepwise ablation of NPAF in large clinical trials may be attributable to proarrhythmic effects of incomplete ablation lines. It is unknown if a more extensive initial ablation strategy results in improved outcomes following multiple ablation procedures.Two hundred twenty two consecutive patients with NPAF underwent first-time ablation using a contact-force sensing ablation catheter utilizing either a stepwise (Group 1, n = 111) or LA PWI (Group 2, n = 111) approach. The duration of follow-up was 36 months. The primary endpoint was freedom from atrial arrhythmia >30 s. Secondary endpoints were freedom from persistent arrhythmia, repeat ablation, and recurrent arrhythmia after repeat ablation.There was similar freedom from atrial arrhythmias after index ablation for both stepwise and LA PWI groups at 36 months (60% vs. 69%, p = .1). The stepwise group was more likely to present with persistent recurrent arrhythmia (29% vs. 14%, p = .005) and more likely to undergo second catheter ablation (32% vs. 12%, p < .001) compared to LA PWI patients. Recurrent arrhythmia after repeat ablation was more likely in the stepwise group compared to the LA PWI group (15% vs. 4%, p = .003).Compared to a stepwise approach, LA PWI for patients with NPAF resulted in a similar incidence of any atrial arrhythmia, lower incidence of persistent arrhythmia, and fewer repeat ablations. Results for repeat ablation were not improved with a more extensive initial approach.