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Multicenter Study
. 2021 Dec 7;23(12):1939-1949.
doi: 10.1093/europace/euab161.

Targeting non-pulmonary vein triggers in persistent atrial fibrillation: results from a prospective, multicentre, observational registry

Domenico G Della Rocca  1 , Luigi Di Biase  1   2   3   4   5 , Sanghamitra Mohanty  1 , Chintan Trivedi  1 , Carola Gianni  1 , Jorge Romero  4 , Nicola Tarantino  4 , Michele Magnocavallo  6 , Mohamed Bassiouny  1 , Veronica N Natale  7 , Angel Quintero Mayedo  1 , Bryan Macdonald  1 , Carlo Lavalle  6 , Ghulam Murtaza  8 , Krishna Akella  8 , Giovanni B Forleo  9 , Amin Al-Ahmad  1 , John David Burkhardt  1 , Gerald Joseph Gallinghouse  1 , Javier E Sanchez  1 , Rodney P Horton  1 , Juan F Viles-Gonzalez  10 , Dhanunjaya Lakkireddy  9 , Andrea Natale  1   2   3   11   12   13
Affiliations
Multicenter Study

Targeting non-pulmonary vein triggers in persistent atrial fibrillation: results from a prospective, multicentre, observational registry

Domenico G Della Rocca et al. Europace. .

Abstract

Aims: We evaluated the efficacy of an ablation strategy empirically targeting pulmonary veins (PVs) and posterior wall (PW) and the prevalence and clinical impact of extrapulmonary trigger inducibility and ablation in a large cohort of patients with persistent atrial fibrillation (PerAF).

Methods and results: A total of 1803 PerAF patients were prospectively enrolled. All patients underwent pulmonary vein antrum isolation (PVAI) extended to the entire PW. A standardized protocol was performed to confirm persistent PVAI and elicit any triggers originating from non-PV sites. All non-PV triggers initiating sustained atrial tachyarrhythmias were ablated. Ablation of non-PV sites triggering non-sustained runs (<30 s) of atrial tachyarrhythmias or promoting frequent premature atrial complexes (≥10/min) was left to operator's discretion. Overall, 1319 (73.2%) patients had documented triggers from non-PV areas. After 17.4 ± 8.5 months of follow-up, the cumulative freedom from atrial tachyarrhythmias among patients without inducible non-PV triggers (n = 484) was 70.2%. Patients with ablation of induced non-PV triggers had a significantly higher arrhythmia control than those whose triggers were not ablated (67.9% vs. 39.4%, respectively; P < 0.001). After adjusting for clinically relevant variables, patients in whom non-PV triggers were documented but not ablated had an increased risk of arrhythmia relapse (hazard ratio: 2.39; 95% confidence interval: 2.01-2.83; P < 0.001).

Conclusion: Pulmonary vein antrum isolation extended to the entire PW might provide acceptable long-term arrhythmia-free survival in PerAF patients without inducible non-PV triggers. In our population of PerAF patients, non-PV triggers could be elicited in ∼70% of PerAF patients and their elimination significantly improved outcomes.

Keywords: Catheter ablation; Non-pulmonary vein triggers; Outcomes; Persistent atrial fibrillation; Pulmonary veins; Registry.

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