This article is more than 5 years old. Information may no longer be current.
Adding linear ablation lesions to pulmonary vein isolation fails to improve outcomes
Click Here to Manage Email Alerts
BOSTON — The addition of linear ablation lesions to pulmonary vein isolation for patients with sustained paroxysmal or persistent atrial fibrillation did not improve outcomes and increased procedure time, radiation dose and fluoroscopy time.
Researchers investigated whether adding bi-atrial linear ablation to wide antral pulmonary vein isolation would reduce recurrence of atrial tachyarrhythmias in those with sustained paroxysmal or persistent AF, for whom pulmonary vein isolation is not always successful.
Gareth J. Wynn
Gareth J. Wynn, MBChB, and colleagues randomly assigned 130 patients (mean age, 61.9 years; 68% men; mean left atrial diameter, 43 mm) to pulmonary vein isolation alone or pulmonary vein isolation plus linear lesions across the left atrial roof, mitral isthmus and tricuspid isthmus; 124 patients underwent their assigned procedure.
All patients had drug-refractory substrate-based AF. Thirty-nine percent had sustained paroxysmal AF, defined as attacks longer than 12 hours with at least one additional clinical marker of abnormal atrial substrate, and 61% had persistent AF for less than 1 year. All patients received antiarrhythmic therapy for 6 weeks before and after their procedure, and all received ECG and Holter monitoring at 3, 6 and 12 months.
The primary outcome was recurrence of atrial tachyarrhythmia for longer than 30 seconds.
Wynn, from the Liverpool Heart and Chest Hospital, Liverpool, United Kingdom, said during a presentation at the Heart Rhythm Society Annual Scientific Sessions that operators achieved successful isolation of 98% of pulmonary veins, and achieved biodirectional conduction block in 90% of linear lesions.
At 12 months, the primary outcome occurred in 38% of the linear ablation group vs. 32% of controls (risk ratio = 0.87; 95% CI, 0.57-1.27), and the results were consistent regardless of persistent AF (linear ablation group, 36%; controls, 28%; P = .45) or sustained paroxysmal AF (linear ablation group, 42%; controls, 39%; P = .86), Wynn said.
Compared with controls, those in the linear ablation group had longer procedure duration (209 minutes vs. 172 minutes; P < .001), longer ablation time (4,352 seconds vs. 2,503 seconds; P < .001), longer fluoroscopy time (1,610 seconds vs. 1,079 seconds; P < .001) and more radiation exposure 3,992 Gy cm2 vs. 2,106 Gy cm2; P = .03), according to Wynn.
Major complications, whether related to the procedure or not, were similar in both groups, and there was one non-CV-related death in the control group, Wynn said.
Quality of life improved for both groups between baseline and final follow-up according to the disease-specific Atrial Fibrillation Effect on Quality of Life score and the Short Form 36 mental component score, but there were no differences between them in improvement (P for AFEQT = .62; P for SF36 = .73).
“Additional linear ablation on top of [wide antral pulmonary vein isolation] prolongs the procedure, increases the fluoroscopy time, increases radiation dose and provides no additional clinical benefit in terms of freedom from arrhythmia or improvement in quality of life,” Wynn said. – by Erik Swain
Reference:
Wynn GJ, et al. Abstract LBCT02-05. Presented at: Heart Rhythm Society Annual Scientific Sessions; May 13-16, 2015; Boston.
Disclosure: Wynn reports no relevant financial disclosures.
Perspective
Back to Top
Michael R. Gold, MD, PhD, FHRS
AF ablation went through an era of more and more extensive ablation. Although the frequency of AF appeared to decline following such ablations, there were more atrial tachycardias. So we may have been creating many pro-arrhythmic episodes while decreasing substrate-dependent arrhythmias. Newer strategies have moved in the direction of ablating as little as possible to reduce AF, but eliminate the risk for pro-arrhythmia associated with incomplete linear ablations and reduce complications associated with more extensive ablation. This was a very nice randomized study to show the benefit of this strategy.
Click Here to Manage Email Alerts