Michele Iavarone, Andrea Rossi, Martina Nesti, Luca Panchetti, Silvia Garibaldi, Umberto Startari, Gianluca Mirizzi, Luigi Cocchiara, Alessandro Valleggi, Francesca Gennaro, Giovanni Mazzotta, Serena Galiberti, Simone Taddeucci, Antonio Agresti, Gianluca Cortis, Federico Landra, Francesco Gentile, Alberto Giannoni, Vincenzo Russo, Marcello Piacenti, Pierfrancesco Grossi, Procolo Marchese
In a real-world PeAF population, a first ablation strategy incorporating VOM-EI, PVI and anatomical linear lesions was significantly more effective than PVI alone in preventing arrhythmic recurrences in a long-term follow-up. Bidirectional block validation across the mitral line and AF duration are key determinants of long-term success. In patients with persistent atrial fibrillation, a first-procedure ablation including vein of Marshall ethanol infusion and an anatomical ablation strategy combining pulmonary vein isolation and linear lesions significantly improved long-term arrhythmia-free survival compared with pulmonary vein isolation alone.
PURPOSE: Pulmonary vein isolation (PVI) ablation has limited efficacy in persistent atrial fibrillation (PeAF). Anatomical strategies combining PVI, vein of Marshall ethanol infusion (VOM-EI), and an anatomical ablation strategy (AS) targeting key atrial isthmuses have shown promising short-term outcomes in this setting.
METHODS: In this retrospective multicenter observational cohort study, consecutive patients with PeAF who underwent either VOM-EI + AS or PVI-only were included. The primary endpoint was freedom from atrial arrhythmias (AAs) lasting > 30 s off antiarrhythmic drugs (AADs). Procedural characteristics and safety outcomes were also evaluated.
RESULTS: After 2:1 propensity score matching, 151 patients treated with VOM-EI + AS were compared with 75 treated with PVI-only. After a median follow-up of 22-month (interquartile range (IQR): 9-35 months), 81% vs. 47% of patients remained free from AA without AADs in the VOM-EI + AS vs. PVI-only group (p < 0.001). Achievement of bidirectional mitral isthmus (MI) block was the strongest independent predictor of arrhythmia-free survival (HR = 0.114; 95% CI: 0.041-0.321; p < 0.001). On the contrary, long-standing PeAF was independently associated with a higher risk of atrial arrhythmic recurrence (HR = 2.68; 95% CI: 1.240-5.812; p = 0.012).
CONCLUSIONS: In a real-world PeAF population, a first ablation strategy incorporating VOM-EI, PVI and anatomical linear lesions was significantly more effective than PVI alone in preventing arrhythmic recurrences in a long-term follow-up. Bidirectional block validation across the mitral line and AF duration are key determinants of long-term success. In patients with persistent atrial fibrillation, a first-procedure ablation including vein of Marshall ethanol infusion and an anatomical ablation strategy combining pulmonary vein isolation and linear lesions significantly improved long-term arrhythmia-free survival compared with pulmonary vein isolation alone.