A minimal or maximal ablation strategy to achieve pulmonary vein isolation for paroxysmal atrial fibrillation: a prospective multi-centre randomized controlled trial (the Minimax study)
Abstract
AIMS: Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation of atrial fibrillation (AF). The intervenous ridge (IVR) may be incorporated into ablation strategies to achieve PVI; however, randomized trials are lacking. We performed a randomized multi-centre international study to compare the outcomes of (i) circumferential antral PVI (CPVI) alone (minimal) vs. (ii) CPVI with IVR ablation to achieve individual PVI (maximal). METHODS AND RESULTS: Two hundred and thirty-four patients with paroxysmal AF underwent CPVI and were randomized to a minimal or maximal ablation strategy. The primary outcome of recurrent atrial arrhythmia was assessed with 7-day Holter monitoring at 6 and 12 months. PVI was achieved in all patients. Radiofrequency ablation time was longer in the maximal group (46.6 ± 14.6 vs. 41.5 ± 13.1 min; P < 0.01), with no significant differences in procedural or fluoroscopy times. At mean follow-up of 17 ± 8 months, there was no difference in freedom from AF after a single procedure between a minimal (70%) and maximal ablation strategy (62%; P = 0.25). In the minimal group, ablation was required on the IVR to achieve electrical isolation in 44%, and was associated with a significant reduction in freedom from AF (57%) compared with the minimal group without IVR ablation (80%; P < 0.01). CONCLUSION: There was no statistically significant difference in freedom from AF between a minimal and maximal ablation strategy. Despite attempts to achieve PVI with antral ablation, IVR ablation is commonly required. Patients in whom antral isolation can be achieved without IVR ablation have higher long-term freedom from AF (the Minimax study; ACTRN12610000863033).
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Extensive left atrial ablation beyond pulmonary vein isolation carries a potentially increased risk of macroreentrant or focal iatrogenic atrial tachycardias, and its value is not well established in patients with paroxysmal or persistent atrial fibrillation.
“However, these techniques carry a potentially increased risk of macroreentrant or focal iatrogenic atrial tachycardias, 197,207 and their value is rather not established in patients with paroxysmal or persistent AF. 208 -210”
From European Heart Rhythm Association (EHRA) consensus document on the management of supraventricular arrhythmias, endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulacion Cardiaca y Electrofisiologia (SOLAECE) (2017) · cites this paper as [208]
Complete pulmonary vein isolation on an atrial level is the best documented target for catheter ablation.
“Complete pulmonary vein isolation (PVI) on an atrial level is the best documented target for catheter ablation, 716,[729][730][731]”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [729]
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 [729]
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Cites
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“3 procedures in patients with paroxysmal AF undergoing catheter ablation.(4) Despite advances in catheter ablation technology, imaging and operator experience PV reconnection remains the ‘achilles heel’ of PV isolation (PVI).”
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BackgroundComplete Isolation of Left Atrium Surrounding the Pulmonary Veins
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Research works printed but not linked: 1
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2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS
Kirchhof, P., Benussi, S., Kotecha, D., Ahlsson, A., Atar, D., Casadei, B., Castella, M., Diener, H.-C., Heidbuchel, H., Hendriks, J., et al. (2016) · European Heart Journal · doi:10.1093/eurheartj/ehw210 · Cited by 6,418 · see citing works
2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS
Kirchhof, P., Benussi, S., Kotecha, D., Ahlsson, A., Atar, D., Casadei, B., Castella, M., Diener, H.-C., Heidbuchel, H., Hendriks, J., et al. (2016) · European Journal of Cardio-Thoracic Surgery · doi:10.1093/ejcts/ezw313 · Cited by 1,403 · see citing works
Katritsis, D. G., Boriani, G., Cosio, F. G., Hindricks, G., Jaïs, P., Josephson, M. E., Keegan, R., Kim, Y.-H., Knight, B. P., Kuck, K.-H., et al. (2017) · Europace · doi:10.1093/europace/euw301 · Cited by 188 · see citing works
- Authors
- McLellan, A. J. A., Ling, L.-H., Azzopardi, S., Lee, G. A., Lee, G., Kumar, S., Wong, M. C. G., Walters, T. E., Lee, J. M., Looi, K.-L., Halloran, K., Stiles, M. K., Lever, N. A., Fynn, S. P., Heck, P. M., Sanders, P., Morton, J. B., Kalman, J. M., & Kistler, P. M.
- Affiliations
- The Royal Melbourne Hospital (AU)
- Baker Heart and Diabetes Institute (AU)
- Royal Papworth Hospital (GB)
- Waikato Hospital (NZ)
- Auckland City Hospital (NZ)
- Royal Adelaide Hospital (AU)
- Corresponding author
- Kistler, Peter M.
- ORCID
- Venue
- European Heart Journal
- Publisher
- Oxford University Press (OUP)
- Published
- 2015-04-28
- Volume
- 36
- Issue
- 28
- Pages
- 1812-1821
- ISSN
- 0195-668X (ISSN-L)
- 1522-9645
- OpenAlex
- W2127251938
- Cited by
- 56
- References
- 15
- Citations by year
- 2026: 1 · 2025: 3 · 2024: 3 · 2023: 4 · 2022: 5 · 2021: 8 · 2020: 3 · 2019: 3 · 2018: 6 · 2017: 7 · 2016: 10 · 2015: 3
- FWCI
- 6.30
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- European Heart Journal (publishedVersion)
- PubMed (publishedVersion)
- 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
- pulmonary vein isolation, paroxysmal atrial fibrillation, catheter ablation, radiofrequency ablation, freedom from atrial fibrillation, ablation strategy
- MeSH terms
- Anti-Arrhythmia Agents, Atrial Fibrillation, Female, Humans, Male, Middle Aged, Prospective Studies, Pulmonary Veins, Recurrence, Reoperation, Electrocardiography, Ambulatory, Treatment Outcome, Catheter Ablation
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