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. 2023 Jun 2;25(6):euad160.
doi: 10.1093/europace/euad160.

Ostial vs. wide area circumferential ablation guided by the Ablation Index in paroxysmal atrial fibrillation

Pedro A Sousa  1 , Sérgio Barra  2 , Carolina Saleiro  1 , Ziad Khoueiry  3 , Luís Adão  4 , João Primo  5 , Philippe Lagrange  3 , Ana Lebreiro  4 , Paulo Fonseca  5 , Mariana Pereira  6 , Luís Puga  1 , Bárbara Oliveiros  7 , Luís Elvas  1 , Lino Gonçalves  1   7
Affiliations

Ostial vs. wide area circumferential ablation guided by the Ablation Index in paroxysmal atrial fibrillation

Pedro A Sousa et al. Europace. .

Abstract

Aims: Pulmonary vein isolation (PVI) guided by the Ablation Index (AI) has shown high acute and mid-term efficacy in the treatment of paroxysmal atrial fibrillation (AF). Previous data before the AI-era had suggested that wide-area circumferential ablation (WACA) was preferable to ostial ablation. However, with the use of AI, we hypothesize that ostial circumferential ablation is non-inferior to WACA and can improve outcomes in paroxysmal AF.

Methods and results: Prospective, multicentre, non-randomized, non-inferiority study of consecutive patients were referred for paroxysmal AF ablation from January 2020 to September 2021. All procedures were performed using the AI software, and patients were separated into two different groups: WACA vs. ostial circumferential ablation. Acute reconnection, procedural data, and 1-year arrhythmia recurrence were assessed. During the enrolment period, 162 patients (64% males, mean age of 60 ± 11 years) fulfilled the study inclusion criteria-81 patients [304 pulmonary vein (PV)] in the WACA group and 81 patients (301 PV) in the ostial group. Acute PV reconnection was identified in 7.9% [95% confidence interval (CI), 4.9-11.1%] of PVs in the WACA group compared with 3.3% (95% CI, 1.8-6.1%) of PVs in the ostial group [P < 0.001 for non-inferiority; adjusted odds ratio 0.51 (95% CI, 0.23-0.83), P = 0.05]. Patients in the WACA group had longer ablation (35 vs. 29 min, P = 0.001) and procedure (121 vs. 102 min, P < 0.001) times. No significant difference in arrhythmia recurrence was seen at 1-year of follow-up [11.1% in WACA vs. 9.9% in ostial, hazard ratio 1.13 (95% CI, 0.44-1.94), P = 0.80 for superiority].

Conclusion: In paroxysmal AF patients treated with tailored AI-guided PVI, ostial circumferential ablation is not inferior to WACA with regard to acute PV reconnection, while allowing quicker procedures with less ablation time.

Keywords: Ablation Index; Acute reconnection; Ostial circumferential; Paroxysmal atrial fibrillation; Pulmonary vein isolation; Wide-area circumferential ablation.

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Conflict of interest statement

Conflict of interest: P.A.S. has received consulting fees from Biosense Webster, Boston Scientific, Medtronic, and Abbott. S.B. has received training grants from Biosense Webster and Biotronik. M.P. is an employee of Biosense Webster. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

Graphical Abstract
Graphical Abstract
Distribution of acute pulmonary vein reconnection in both groups [wide-area circumferential ablation (WACA) vs. ostial] (central panel), with an illustration of the typical location for ablation lines in each corresponding group, in a posterior view (left panel). Ostial ablation was not inferior to WACA with regard to acute pulmonary vein reconnections (P < 0.001 for non-inferiority; P = 0.05 adjusted for superiority) and arrhythmia recurrence at 1-year of follow-up (P < 0.001 for non-inferiority; P = 0.80 for superiority), while requiring less ablation (P = 0.001) and allowing for quicker procedures (P < 0.001) (right panel).
Figure 1
Figure 1
Examples of cases illustrating the distribution of RF lesions on both groups (A–C correspond to ostial ablation, while D–F correspond to WACA). RF, radiofrequency; WACA, wide-area circumferential ablation.
Figure 2
Figure 2
Diagram showing the eight-segment per PV encirclement used for analysis and the number of acute reconnections (spontaneous and provoked by adenosine) with the corresponding AI values on both groups. AI, Ablation Index; PV, pulmonary vein; LIPV, left inferior pulmonary vein; LSPV, left superior pulmonary vein; RIPV, right inferior pulmonary vein; RSPV, right superior pulmonary vein; WACA, wide-area circumferential ablation.
Figure 3
Figure 3
Diagram presenting the 95% CI for the expected difference between Groups A (ostial group) and B (WACA group) in the population (95% CI Diff) and the P-value for the unilateral test the superiority test. The right vertical line represents the null difference between study Groups A and B and the expected rates (95% CI) of reconnection in each study group presented in light grey. CI, confidence interval; WACA, wide-area circumferential ablation.
Figure 4
Figure 4
Freedom from recurrence of atrial arrhythmia following PVI guided by AI in the WACA group vs. the ostial group (11.1 vs. 9.9%, P < 0.001 for non-inferiority; P = 0.80 for superiority). AI, Ablation Index; PVI, pulmonary vein isolation; WACA, wide-area circumferential ablation.
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