Approaches to catheter ablation for persistent atrial fibrillation
Open accessAbstract
BACKGROUND: Catheter ablation is less successful for persistent atrial fibrillation than for paroxysmal atrial fibrillation. Guidelines suggest that adjuvant substrate modification in addition to pulmonary-vein isolation is required in persistent atrial fibrillation. METHODS: We randomly assigned 589 patients with persistent atrial fibrillation in a 1:4:4 ratio to ablation with pulmonary-vein isolation alone (67 patients), pulmonary-vein isolation plus ablation of electrograms showing complex fractionated activity (263 patients), or pulmonary-vein isolation plus additional linear ablation across the left atrial roof and mitral valve isthmus (259 patients). The duration of follow-up was 18 months. The primary end point was freedom from any documented recurrence of atrial fibrillation lasting longer than 30 seconds after a single ablation procedure. RESULTS: Procedure time was significantly shorter for pulmonary-vein isolation alone than for the other two procedures (P<0.001). After 18 months, 59% of patients assigned to pulmonary-vein isolation alone were free from recurrent atrial fibrillation, as compared with 49% of patients assigned to pulmonary-vein isolation plus complex electrogram ablation and 46% of patients assigned to pulmonary-vein isolation plus linear ablation (P=0.15). There were also no significant differences among the three groups for the secondary end points, including freedom from atrial fibrillation after two ablation procedures and freedom from any atrial arrhythmia. Complications included tamponade (three patients), stroke or transient ischemic attack (three patients), and atrioesophageal fistula (one patient). CONCLUSIONS: Among patients with persistent atrial fibrillation, we found no reduction in the rate of recurrent atrial fibrillation when either linear ablation or ablation of complex fractionated electrograms was performed in addition to pulmonary-vein isolation. (Funded by St. Jude Medical; ClinicalTrials.gov number, NCT01203748.).
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Pulmonary vein isolation appears to be non-inferior to more extensive ablation in persistent atrial fibrillation.
“PVI was initially tested in patients with paroxysmal AF, but appears to be non-inferior to more extensive ablation in persistent AF as well.729,735”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [735]
Sinus rhythm without severely symptomatic recurrences of atrial fibrillation is found in up to 70% of patients with paroxysmal atrial fibrillation and around 50% in persistent atrial fibrillation.
“Sinus rhythm without severely symptomatic recurrences of AF is found in up to 70% of patients with paroxysmal AF, and around 50% in persistent AF. 713,728,735,1042”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [735]
The added value of additional ablation techniques is questionable in patients undergoing a first catheter ablation, including those with persistent AF.
“Although a plethora of different additional ablation techniques have been published, their added value is questionable in patients undergoing a first catheter ablation, including those with persistent AF. 735”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [735]
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Self-citationTranslational Challenges in Atrial Fibrillation
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Self-citationCryoballoon Ablation as Initial Treatment for Atrial Fibrillation
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Self-citationProgress in atrial fibrillation ablation during 25 years of Europace journal
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A Novel Mapping System for Panoramic Mapping of the Left Atrium
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- Authors
- Verma, A., Jiang, C.-Y., Betts, T. R., Chen, J., Deisenhofer, I., Mantovan, R., Macle, L., Morillo, C. A., Haverkamp, W., Weerasooriya, R., Albenque, J.-P., Nardi, S., Menardi, E., Novak, P., & Sanders, P.
- Affiliations
- Montreal Heart Institute (CA)
- John Radcliffe Hospital (GB)
- Haukeland University Hospital (NO)
- Deutsches Herzzentrum München (DE)
- Ospedale “M. Bufalini” di Cesena (IT)
- McMaster University (CA)
- Charité – Universitätsmedizin Berlin (DE)
- Hollywood Private Hospital (AU)
- Clinique Pasteur (FR)
- Azienda Sanitaria Ospedaliera S.Croce e Carle Cuneo (IT)
- Royal Jubilee Hospital (CA)
- Royal Adelaide Hospital (AU)
- ORCID
- Venue
- New England Journal of Medicine
- Publisher
- Massachusetts Medical Society
- Published
- 2015-05-07
- Volume
- 372
- Issue
- 19
- Pages
- 1812-1822
- ISSN
- 0028-4793 (ISSN-L)
- 1533-4406
- OpenAlex
- W1583406651
- Cited by
- 2,339
- References
- 33
- Citations by year
- 2026: 162 · 2025: 191 · 2024: 213 · 2023: 176 · 2022: 253 · 2021: 186 · 2020: 231 · 2019: 222 · 2018: 205 · 2017: 227 · 2016: 193 · 2015: 71 · 2014: 1 · 2013: 2 · 2012: 1
- FWCI
- 168.71
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- New England Journal of Medicine (publishedVersion)
- PubMed (publishedVersion)
- UWA Profiles and Research Repository (UWA) (submittedVersion)
- Adelaide Research & Scholarship (AR&S) (University of Adelaide) (submittedVersion)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Arrhythmias and Treatments
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac pacing and defibrillation studies
- Keywords
- persistent atrial fibrillation, catheter ablation, pulmonary vein isolation, complex fractionated atrial electrograms, linear ablation, left atrial roof, atrial fibrillation recurrence
- MeSH terms
- Aged, Atrial Fibrillation, Electrocardiography, Female, Heart Atria, Humans, Male, Middle Aged, Mitral Valve, Pulmonary Veins, Recurrence, Stroke Volume, Proportional Hazards Models, Catheter Ablation, Disease-Free Survival, Kaplan-Meier Estimate, Secondary Prevention, Operative Time
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