Four PVI techniques conferred similar efficacy in treating persistent AF
Key takeaways:
- Four different pulmonary vein isolation techniques demonstrated similar efficacy in treating persistent AF.
- Arrhythmia recurrence occurred in nearly half of all patients in the 12 to 18 months after ablation.
Ostial and antral pulmonary vein isolation, ablation plus posterior wall isolation and cryoablation all demonstrated comparable success in treating persistent atrial fibrillation, according to a post hoc analysis of the DECAAF II trial.
“Ablation of persistent AF remains challenging, with substantial rates of recurrence,” Charbel Noujaim, MD, MSc, postdoctoral research fellow at Tulane Research Innovation for Arrhythmia Discovery at Tulane University School of Medicine, and colleagues wrote. “Current studies do not suggest a routine benefit with more extensive ablation beyond pulmonary vein isolation (PVI) alone and the optimal ablation strategy for these patients remains unclear. We sought to compare the procedural outcomes of four ablation approaches in the DECAAF II study population: antral PVI, ostial PVI, antral PVI [plus] posterior wall isolation, and cryoballoon PVI.”
DECAAF II was an investigator-initiated trial for which researchers randomly assigned 843 patients with persistent AF to ablation based on MRI assessment of atrial fibrosis or conventional PVI. Patients were followed up for 12 to 18 months and the primary outcome was recurrence of atrial arrhythmia.
As Healio previously reported, ablation based on MRI assessment of atrial fibrosis was not superior to PVI for prevention of arrhythmia recurrence in patients with persistent AF.
This post hoc analysis included 367 DECAAF II participants (mean age, 62; 77% men; mean left atrial fibrosis, 19%) from the conventional PVI arm of the study. The primary outcome was the first confirmed atrial arrhythmia recurrence lasting 30 seconds or more after the initial blanking period.
Arrhythmia recurrence was monitored daily with a hand-held smartphone ECG device (ECG Check, Cardiac Designs) for 12 to 18 months.
The results were published in Circulation: Arrhythmia and Electrophysiology.
Overall, 57% underwent ostial PVI, 22% underwent antral PVI, 8% underwent PVI plus posterior wall isolation and 12% underwent cryoablation.
The researchers reported no significant difference in recurrence rates across all four ablation categories (log-rank P = .76):
- 43% recurrence in the ostial PVI group;
- 48% recurrence in the antral PVI group;
- 39% recurrence in the PVI plus posterior wall isolation group; and
- 50% in the cryoablation group.
Moreover, AF burden during the blanking period was the only significant independent predictor of arrhythmia recurrence (OR = 3.8; P < .0001), according to the study.
“The overall recurrence rate of arrhythmia was approximately 40% to 50%, even with more extensive ablation methods. This rate is consistent with previous studies reporting up to 50% recurrence in patients with persistent AF,” the researchers wrote. “All PVI techniques are equally effective in terms of atrial arrhythmia recurrence in patients with persistent AF undergoing first-time catheter ablation. Adjunctive PVI plus posterior wall isolation did not provide any additional benefit in this population. Nonetheless, further studies are needed to determine the optimal ablation strategy in patients with persistent AF, as PVI alone leads to substantial rates of recurrence regardless of approach.”
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