EXPORT Randomized Trial

Comparison of Circumferential Pulmonary Vein (PV) Isolation Alone Versus Additional EXtra-PulmOnaRy Vein Trigger Ablation in Persistent Atrial Fibrillation

Pulmonary Vein Isolation (PVI)-Only Group

1. Pulmonary vein isolation (PVI) will be performed, and the procedure will be terminated without the administration of isoproterenol following the standard waiting period.
2. In cases where spontaneous triggers are observed following PVI, mapping and ablation of the identified triggers are permitted.
3. Post-procedural rhythm monitoring and follow-up will be conducted in accordance with the predefined study protocol.

Additional Non-Pulmonary Vein (Non-PV) Trigger Ablation Group

Isoproterenol will be administered starting at 5 μg/min, with stepwise increases to 10 μg/min and 20 μg/min at 3-5 minute intervals, as tolerated, aiming to achieve 85% of the maximum predicted heart rate, with a maximum dose of 30 μg/min.The total infusion duration will be at least 10 minutes.

• If systolic blood pressure (SBP) decreases by ≥20 mmHg from the baseline (prior to infusion), the isoproterenol infusion will be discontinued.
• If hypotension is anticipated or occurs during isoproterenol infusion, phenylephrine infusion may be administered to maintain SBP between 120-140 mmHg.
• For patients with a history of coronary artery disease, heart failure, or valvular heart disease, the maximum isoproterenol infusion rate may be limited to ≤10 μg/min at the discretion of the operator.

Study Overview

• Status: Not yet recruiting
• Conditions: Atrial Fibrillation
• Intervention / Treatment: Procedure: Additional extra-pulmonary vein trigger ablation group; Procedure: Empirical pulmonary vein isolation group

Detailed Description

"A. Essential Standard Pre-Procedural Examinations for Catheter Ablation

• Transthoracic Echocardiography (TTE): Performed in all patients to evaluate the presence of structural heart disease, left atrial size, and left ventricular function. Findings guide the selection of antiarrhythmic medications and assist in determining procedural indications.
• Transesophageal or Intracardiac Echocardiography: Conducted in all patients prior to the procedure to detect thrombi within the left atrial appendage, thereby minimizing the risk of post-procedural cerebrovascular events.
• Three-Dimensional Cardiac CT Imaging (substitutable with Cardiac Magnetic Resonance Imaging if clinically indicated): Performed in all patients before the procedure to generate a three-dimensional anatomical model of the left atrium by integrating voltage mapping and contour data from CT images. This approach enhances procedural accuracy and reduces the incidence of procedure-related complications.
• The most recent test results prior to the procedure should be utilized preferentially; in the absence of recent data, prior examination results may be used as substitutes.

B. Administration of Medications Before and After Catheter Ablation

• Anticoagulant therapy will be administered for a period of one month prior to and for a minimum of two months following the catheter ablation procedure, in order to reduce the risk of thromboembolic events, including stroke. Should the risk of stroke remain elevated due to atrial fibrillation recurrence or other clinical considerations, continuation of anticoagulation therapy may be determined at the discretion of the treating physician.
• In cases where recurrence of atrial fibrillation is suspected, or if there is a clinically assessed high likelihood of recurrence, antiarrhythmic medications may be prescribed based on the clinical judgment of the physician.

• Study Type: Interventional
• Enrollment (Estimated): 406
• Phase: Not Applicable

Contacts and Locations

Study Locations

• South Korea
  • Seoul, South Korea, 120-752
    • Severance Cardiovascular Hospital, Yonsei University Health System

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Patients aged ≥19 years with persistent atrial fibrillation scheduled for catheter ablation.
• Refractory to or intolerant of at least one Class I or III antiarrhythmic drug.
• Undergoing first-time catheter ablation for atrial fibrillation.

Exclusion Criteria:

• Acute coronary syndrome within the past 3 months.
• Severe unrevascularized coronary artery disease: ≥70% stenosis in at least one major epicardial vessel with a diameter ≥2 mm.
• History of stroke or transient ischemic attack (TIA) within the past 3 months.
• Uncontrolled severe hypertension (systolic blood pressure ≥180 mmHg or diastolic blood pressure ≥120 mmHg).
• Severe untreated aortic valve stenosis.
• Symptomatic moderate-to-severe valvular heart disease.
• Aortic dissection.
• Heart failure with reduced ejection fraction (LVEF <40%).
• Severe pulmonary hypertension (resting RVSP >60 mmHg).
• Left atrial anteroposterior diameter >60 mm.
• Presence of cyanotic congenital heart disease.
• Obstructive hypertrophic cardiomyopathy (resting or provoked LVOT pressure gradient ≥30 mmHg).
• History of prior maze surgery or catheter ablation for atrial fibrillation.
• Active internal bleeding.
• Contraindications to anticoagulation therapy or rhythm control treatment.
• Presence of severe comorbid conditions or life expectancy <1 year.
• Drug or alcohol abuse.
• Pregnancy.
• Any other condition that, in the investigator's judgment, makes the patient unsuitable for study participation.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Additional extra-pulmonary vein trigger ablation group; circumferential pulmonary vein isolation with additive induction, mapping, and ablation of non-pulmonary vein trigger	Procedure: Additional extra-pulmonary vein trigger ablation group; Circumferential PVI is performed in all patients.; After PVI, isoproterenol is infused starting at 5 μg/min, increased every 3-5 min to 10 and 20 μg/min (max 30 μg/min) to reach 85% of predicted heart rate for ≥10 min.2-1) If AF persists, internal cardioversion (5-30 J) is performed using catheters in the right atrium and coronary sinus.2-2) If sinus rhythm is present, a 15-beat drive train (10 mA, 2 ms) is delivered at 250 ms, shortened by 10 ms to 180 ms or until capture fails, up to three times, to induce AF or AT. Isoproterenol continues for 2 min. If arrhythmia occurs, cardioversion is repeated.; After cardioversion, isoproterenol is stopped and the patient is observed for 10 min.; Sustained or reproducible arrhythmias are defined as non-PV triggers.; These are localized with activation mapping, P-wave analysis, and high-density mapping.; Ablation is performed with the same catheter.; Reassessment is done with the same protocol.
Active Comparator: Empirical pulmonary vein isolation group; circumferential pulmonary vein isolation only	Procedure: Empirical pulmonary vein isolation group; Circumferential pulmonary vein isolation (PVI) is performed in all patients.; After PVI, a waiting period of at least 20 minutes is observed, followed by reassessment of pulmonary vein isolation before concluding the procedure.; Additional linear ablation or CFAE ablation not specified in the study protocol should be avoided whenever possible.; In cases where typical atrial flutter has been documented prior to the procedure or is induced during the procedure, cavo-tricuspid isthmus (CTI) ablation is performed. At the operator's discretion, CTI ablation may also be permitted even in patients without a prior history or inducibility.; If atypical atrial flutter involving these pathways is induced during the procedure, additional linear ablation (e.g., roof line, posterior-inferior line, left lateral isthmus, or anterior line) may be performed.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Recurrence of atrial arrhythmia	any documented atrial arrhythmia lasting ≥30 seconds after a 3-month blanking period following ablation with or without the use of antiarrhythmic drug use	within 24 months after enrollement

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Recurrence of atrial arrhythmia or use of antiarrhythmic drug	any documented atrial arrhythmia lasting ≥30 seconds after a 3-month blanking period following ablation or the use of antiarrhythmic drug use	within 24 months after enrollement
Recurrence of atrial fibrillation	any documented atrial fibrillation lasting ≥30 seconds after a 3-month blanking period following ablation with or without the use of antiarrhythmic drug use	within 24 months after enrollement
Recurrence of atrial tachycardia/flutter	any documented atrial tachycardia/flutter lasting ≥30 seconds after a 3-month blanking period following ablation with or without the use of antiarrhythmic drug use	within 24 months after enrollement
Cardioversion rate	any cardioversion performed following ablation	within 24 months after enrollement
Complication rate	any complication related to ablation	within 24 months after enrollement

Collaborators and Investigators

• Sponsor: Yonsei University

Study record dates

Study Major Dates

• Study Start (Estimated): October 1, 2025
• Primary Completion (Estimated): August 31, 2029
• Study Completion (Estimated): August 31, 2030

Study Registration Dates

• First Submitted: September 26, 2025
• First Submitted That Met QC Criteria: September 26, 2025
• First Posted (Estimated): September 30, 2025

Study Record Updates

• Last Update Posted (Estimated): September 30, 2025
• Last Update Submitted That Met QC Criteria: September 26, 2025
• Last Verified: September 1, 2025

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Cardiovascular Diseases; Pathologic Processes; Heart Diseases; Arrhythmias, Cardiac; Pathological Conditions, Signs and Symptoms; Atrial Fibrillation
• Other Study ID Numbers: 2025-1476-001

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: UNDECIDED

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No