Optimal substrate modification strategies using catheter ablation in patients with persistent atrial fibrillation: 3-year follow-up outcomes

Yu-Cheng Hsieh, Yenn-Jiang Lin, Men-Tzung Lo, Yun-Yu Chen, Chin-Yu Lin, Chen Lin, Fa-Po Chung, Li-Wei Lo, Shih-Lin Chang, Tze-Fan Chao, Yu-Feng Hu, Ta-Chuan Tuan, Jo-Nan Liao, Cheng-I Wu, Chih-Min Liu, Jennifer-Jeanne B Vicera, Chun-Chao Chen, Chye-Gen Chin, Isaiah C Lugtu, Shih-Ann Chen, Yu-Cheng Hsieh, Yenn-Jiang Lin, Men-Tzung Lo, Yun-Yu Chen, Chin-Yu Lin, Chen Lin, Fa-Po Chung, Li-Wei Lo, Shih-Lin Chang, Tze-Fan Chao, Yu-Feng Hu, Ta-Chuan Tuan, Jo-Nan Liao, Cheng-I Wu, Chih-Min Liu, Jennifer-Jeanne B Vicera, Chun-Chao Chen, Chye-Gen Chin, Isaiah C Lugtu, Shih-Ann Chen

Abstract

Objectives: This study aimed to assess the comparative efficacy of four ablation strategies on the incidence rates of freedom from atrial fibrillation (AF) or atrial tachycardia (AT) through a 3-year follow-up in patients with persistent AF.

Background: The optimal substrate modification strategies using catheter ablation for patients with persistent AF remain unclear.

Methods: Patients with persistent AF were enrolled consecutively to undergo each of four ablation strategies: (a) Group 1 (Gp 1, n = 69), pulmonary vein isolation (PVI) plus rotor ablation assisted by similarity index and phase mapping; (b) Gp 2 (n = 75), PVI plus linear ablations at the left atrium; (c) Gp 3 (n = 42), PVI plus the elimination of complex fractionated atrial electrograms; (d) Gp 4 (n = 67), PVI only. Potential confounders were adjusted via a multivariate survival parametric model.

Results: Baseline characteristics were similar across the four groups. At a follow-up period of 34.9 ± 38.6 months, patients in Gp 1 showed the highest rate of freedom from AF compared with the other three groups (p = .002), while patients in Gp 3 and 4 showed lower rates of freedom from AT than those of the other two groups (p = .006). Independent predictors of recurrence of AF were the ablation strategy (p = .002) and left atrial diameter (LAD) (p = .01).

Conclusion: In patients with persistent AF, a substrate modification strategy using rotor ablation assisted by similarity index and phase mapping provided a benefit for maintaining sinus rhythm compared with the other strategies. Both ablation strategy and baseline LAD predicted the 3-year outcomes of freedom from AT/AF.

Keywords: atrial tachycardia; persistent atrial fibrillation; phase map; pulmonary vein isolation; similarity index; substrate.

© 2021 The Authors. Journal of Cardiovascular Electrophysiology Published by Wiley Periodicals LLC.

Figures

Figure 1
Figure 1
Flowchart of the study protocol for patients with persistent atrial fibrillation. CFAE, complex fractionated atrial electrograms; PVI, pulmonary vein isolation
Figure 2
Figure 2
Illustrations of the four ablation strategies. CFAE, complex fractionated atrial electrograms; PVI, pulmonary vein isolation; SI, similarity index
Figure 3
Figure 3
Example of rotor identification assisted by similarity index (SI). SI was quantified based on the temporal and spatial consistency of morphological repetitiveness of local activation wave (LAW). Rotors were then identified in the high SI region
Figure 4
Figure 4
Predicted event‐free survival curves adjusted by multivariate Cox proportional model for (A) AF, (B) AT, and (C) AF plus AT recurrence in the four groups of patients. AF, atrial fibrillation; AT, atrial tachycardia. The numbers of patients at risk at each time point were before model adjustment

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