Stand-Alone Pulmonary Vein Isolation Versus Pulmonary Vein Isolation With Additional Substrate Modification as Index Ablation Procedures in Patients With Persistent and Long-Standing Persistent Atrial Fibrillation: The Randomized Alster-Lost-AF Trial (Ablation at St. Georg Hospital for Long-Standing Persistent Atrial Fibrillation). (July 2017)

• Record Type: Journal Article
• Authors: Fink, Thomas; Schlüter, Michael; Heeger, Christian-Hendrik; Lemes, Christine; Maurer, Tilman; Reissmann, Bruno; Riedl, Johannes; Rottner, Laura; Santoro, Francesco; Schmidt, Boris; Wohlmuth, Peter; Mathew, Shibu; Sohns, Christian; Ouyang, Feifan; Metzner, Andreas; Kuck, Karl-Heinz
• Is Part Of: Circulation. Volume 10:Number 7(2017)
• Publication Date: 2017-07
• Subjects: atrial fibrillation -- catheter ablation -- recurrence -- tachycardia; Arrhythmia -- Periodicals; Heart -- Electric properties -- Periodicals; 616.128
• DOI: 10.1161/CIRCEP.117.005114
• Languages: English
• ISSNs: 1941-3149

Abstract

Abstract : Background—: Pulmonary vein isolation (PVI) for persistent atrial fibrillation is associated with limited success rates and often requires multiple procedures to maintain stable sinus rhythm. In the prospective and randomized Alster-Lost-AF trial (Ablation at St. Georg Hospital for Long-Standing Persistent Atrial Fibrillation), we sought to assess, in patients with symptomatic persistent or long-standing persistent atrial fibrillation, the outcomes of initial ablative strategies comprising either stand-alone PVI (PVI-only approach) or a stepwise approach of PVI followed by complex fractionated atrial electrogram ablation and linear ablation (Substrate-modification approach). Methods and Results—: Patients were randomized 1:1 to stand-alone PVI or PVI plus substrate modification. The primary study end point was freedom from recurrence of any atrial tachyarrhythmia, outside a 90-day blanking period, at 12 months. A total of 124 patients were enrolled, with 118 patients included in the analysis (61 in the PVI-only group, 57 in the Substrate-modification group). Atrial tachyarrhythmias recurred in 28 PVI-only group patients and 24 Substrate-modification group patients, for 1-year freedom from tachyarrhythmia recurrence after a single ablation procedure of 54% (95% confidence interval, 43%–68%) in the PVI-only and 57% (95% confidence interval, 46%–72%) in the Substrate-modification group ( P =0.86). Twenty-four patients in the PVI-only group (39%) and 18 in the Substrate-modification group (32%) were without arrhythmia recurrence and off antiarrhythmic drug therapy at the end of the 12-month follow-up. Conclusions—: In patients with persistent and long-standing persistent atrial fibrillation, no significant difference was observed in 12-month freedom from atrial tachyarrhythmias between an index ablative approach of stand-alone PVI and a stepwise approach of PVI plus complex fractionated atrial electrogram and linear ablation. Clinical Trial Registration—: URL:http://www.clinicaltrials.gov . Unique identifier: NCT00820625.