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. 2023 Jul 15;12(14):4698.
doi: 10.3390/jcm12144698.

CLOSE-Guided Pulmonary Vein Isolation to Treat Persistent Atrial Fibrillation: 1-Year Outcome

Philippe Taghji  1 , Jean-Claude Deharo  1 , Sana Amraoui  2 , Sok-Sithikun Bun  3
Affiliations

CLOSE-Guided Pulmonary Vein Isolation to Treat Persistent Atrial Fibrillation: 1-Year Outcome

Philippe Taghji et al. J Clin Med. .

Abstract

Background: CLOSE-guided pulmonary vein isolation (PVI) is based on contiguous and optimized (Ablation Index-guided) radiofrequency lesions. The efficacy of CLOSE-guided PVI in persistent atrial fibrillation (AF) treatment has been poorly evaluated.

Methods: In two centers, 50 patients eligible for persistent AF ablation underwent CLOSE-guided PVI (Ablation Index ≥ 450 at the anterior wall, ≥300 at posterior wall, intertag distance ≤ 6 mm). If PVI failed to restore sinus rhythm (SR), electrical cardioversion (ECV) was performed. Atrial substrate modification (ASM) was performed only if PVI and ECV failed to restore SR. Recurrence was defined as any recorded episode of AF, atrial tachycardia (AT) or atrial flutter (AFL) > 30 s on Holter electrocardiographs at 3, 6 and 12 months.

Results: From the 50 patients (64 ± 10 years, 14% long-standing persistent AF), SR was restored by ECV in 34 patients (68%) 56 ± 38 days prior to ablation. On the day of ablation, 42 patients (84%) were on class I-III anti-arrhythmic drug therapy (ADT) and the rhythm was AF in 23/50 patients. PVI was achieved in all patients; after PVI, ECV was required in 21 patients and ASM in 1 patient. The mean procedure time, radiofrequency time and fluoroscopy time were 141 ± 33 min, 23 ± 7 min and 7 ± 6 min, respectively. At 12 months, single-procedure freedom from AF/AT/AFL was 80%, with 19 patients (38%) receiving class I-III ADT.

Conclusions: In a population of patients with persistent AF monitored with intermittent cardiac rhythm recordings, CLOSE-guided PVI resulted in high single-procedure arrhythmia-free survival at 1 year. Future large-scale studies involving continuous cardiac monitoring are necessary.

Keywords: CLOSE-guided ablation; atrial fibrillation; persistent atrial fibrillation; pulmonary vein isolation; single-procedure arrhythmia-free survival.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
Study workflow. AF = atrial fibrillation; AFL= atrial flutter; AT = atrial tachycardia; BP = blanking period; CEID = cardiac electronic implantable device; CTI = cavotricuspid isthmus; ECG = electrocardiogram; ECV = electrical cardioversion; EGM = electrogram; ICM = insertable cardiac monitor; LASM = left atrium substrate modification; PVI = pulmonary veins isolation; SR = sinus rhythm. * Outpatient ECV was encouraged prior to ablation.
Figure 2
Figure 2
Region specific Ablation Index target with intertag distance. Left panel, RAO 30° view: AI target ≥ 450 au on the AW (red-colored tag), AI target ≥ 300 au on the PW and roof (pink-colored tag). Intertag distance target was ≤6 mm. Right panel, PA view: at the vicinity of esophagus (localized by preprocedure tomodensitometry or if esophageal probe temperature rise ≥ 38.5 °C), intertag distance target was ≤7 mm. RAO = right anterior oblique; AI = Ablation Index; au = arbitrary unit; AW = anterior wall; PW = posterior wall; PA = postero-anterior.
Figure 3
Figure 3
Survival plot after ablation. Kaplan-Meier curve depicting time to first recurrence of atrial fibrillation (AF), atrial tachycardia (AT), or atrial flutter (AFL), (including a 3-month blanking period) in all 50 patients undergoing CLOSE-guided ablation. At 12 months, 19 patients (38%) were still on anti-arrhythmic drug therapy.
Figure 4
Figure 4
Survival plots for patient subgroups. Kaplan-Meier curves depicting time to first recurrence of AF (atrial fibrillation), AT (atrial tachycardia), or AFL (atrial flutter) in patients undergoing single procedure of CLOSE-guided PVI for subgroup of patients taking antiarrhythmic drug therapy (ADT) (upper left) or not taking ADT (upper right) and time to first recurrence of persistent AF, AT or AFL in patients in AF at ablation start (lower left) or in sinus rhythm (SR) of AFL at ablation start (lower right).
Figure 5
Figure 5
Subtypes of atrial tachyarrhythmia (>30 s) and ADT evolution throughout the study (n = 50). ADT = anti-arrhythmic drug therapy; AF = atrial fibrillation; AFL = atrial flutter; AT = atrial tachycardia; BP = blanking period; SR = sinus rhythm. * 34/50 pts underwent a scheduled electrical cardioversion (ECV) prior to ablation. ** ECV was performed only during the BP in 8 patients; no patient underwent repeat ablation. ADT was maintained in 38% of patients at 12 months. *** paroxysmal: AF, AT or AFL episode < 24 h on Holter ECG recording or 2 ECG performed within a 7 days period showing SR at least one time.
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