Pulmonary vein activity does not predict the outcome of catheter ablation for persistent atrial fibrillation: A long-term multicenter prospective study

Abstract

Background: Pulmonary vein (PV) isolation (PVI) remains the cornerstone of catheter ablation (CA) in persistent atrial fibrillation (AF) (PeAF), although less successful than for paroxysmal AF. Whether rapid or fibrillatory (PV AF) PV firing may identify patients with PeAF more likely to benefit from a PV-based ablation approach is unclear.

Objective: The purpose of this study was to determine the relationship between the PV cycle length (PVCL) and the PV AF outcome after CA.

Methods: Before ablation, the multipolar catheter was placed in each PV and the left atrial appendage (LAA) for 100 consecutive cycles. The presence of PV AF, the average PVCL of all 4 veins (PV_4VAverage), the fastest vein average (PV_FVAverage), the fastest cycle length (PV_Fast) both individually and relative to the average LAA cycle length were calculated. The ablation strategy included PVI and posterior wall isolation with a minimum of 12 months follow-up.

Results: A total of 123 patients underwent CA (age 62 ± 9.1 years; CHA₂DS₂-VASC score 1.6 ± 1.1; left ventricular ejection fraction 48% ± 13%; left atrial area 31 ± 8.7 cm²; AF duration 16 ± 17 months). PVI was achieved in 100% of patients. Multiprocedure success (MPS; freedom from AF/atrial tachycardia episodes lasting >30 seconds) was achieved in 76% of patients at 24 ± 8.1 months of follow-up after 1.2 ± 0.4 procedures. PV activity was not associated with MPS either absolutely (PV_4VAverage [MPS no vs yes: 178 ± 27 ms vs 177 ± 24 ms; P = .92], PV_FVAverage [P = .69], or PV_Fast [P = .82]) or as a ratio relative to the LAA cycle length (PV_4VAverage/LAA 1.05 ± 0.11 vs 1.06 ± 0.21; P = .87). The presence of PV AF (31% vs 47%; P = .13) did not predict MPS.

Conclusion: The rapidity of PV firing or presence of fibrillation within the PV was not predictive of outcome of CA for PeAF. PV activity does not identify patients most likely to benefit from a PV-based ablation strategy.

Keywords: Catheter ablation; Catheter ablation outcomes; Persistent atrial fibrillation; Pulmonary vein cycle length; Pulmonary vein electrical activity.