Ablation Strategies for Persistent Atrial Fibrillation: Beyond the Pulmonary Veins
Abstract
:1. Introduction
2. Ablation Strategies
2.1. Radiofrequency Ablation and Cryoablation
2.2. Pulsed-Field Ablation
2.3. Hybrid Ablation
2.3.1. Thoracoscopic Ablation
2.3.2. Hybrid Convergent Ablation
3. Non-Pulmonary Vein Triggers (NPVTs)
3.1. Left Atrial Posterior Wall
3.2. Left Atrial Appendage (LAA)
3.3. Superior Vena Cava (SVC)
3.4. CFAEs, Rotors, and Dispersion
3.5. Vein of Marshall Ethanol Ablation
3.6. Low-Voltage Areas
3.7. Crista Terminalis
4. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Ablation Target | Study | Study Population | Study Design | Outcome |
---|---|---|---|---|
Left atrial posterior wall (LAPW) | Kistler 2023 (CAPLA trial) | 338 symptomatic patients with PeAF | Multicenter, randomized 1:1 to either PVI with PWI (n = 170) or PVI alone (n = 168) | Addition of PWI to PVI did not significantly improve freedom from AA compared with PVI alone [HR, 0.99 [95% CI, 0.73–1.36]; p = 0.98). |
Kim 2015 (prospective RCT) | 120 PeAF patients followed for 12 months after RFCA | Linear ablation + CPVI + PWI (n = 60) vs. linear ablation + CPVI (n = 60) | PWI (+) group had higher AF termination during procedure (p = 0.035), and lower AF recurrence on follow-up (17% vs. 37%, p = 0.02) | |
Tamborero 2008 (prospective RCT) | 120 patients with AF | Prospective, randomized to CPVI + PWI (n = 60) vs. CPVI alone (n = 60) | PWI did not improve freedom from AA recurrence in patients undergoing CPVI. (log-rank test p = 0.943) | |
Wong 2023 (PEF-HOT trial) | 67 patients with PeAF using high-power short- duration ablation (HPSD) | Multicenter, open-label, single-blind, randomized to PVI + PWI (n = 39) vs. PVI alone (n = 28) | AA recurrence rates did not significantly differ between PVI + PWI and PVI-only groups (25.6% vs. 28.6%; p = 0.7895) | |
Left atrial appendage (LAA) | Di Biase 2016 (BELIEF Trial) | 173 patients with long-standing PeAF | Open-label, randomized to empirical LAAEI + extensive ablation (n = 85) vs. extensive ablation alone (n = 88) | LAAEI improved long-term freedom from AAs without increasing complications. (unadjusted HR: 2.24; 95% CI: 1.3 to 3.8; log-rank p = 0.003) |
Lakkireddy 2024 (aMAZE RCT) | 404 patients with non-paroxysmal AF | Multicenter, prospective, open-label, randomized 2:1 to PVI + LAA ligation (n = 404) vs. PVI alone (n = 206) | Freedom from AAs was 64.3% with LAAI + PVI and was not superior to 59.9% with PVI only (difference, 4.3% [Bayesian 95% credible interval, −4.2% to 13.2%]; posterior superiority probability, 0.835) | |
Superior vena cava (SVC) | Dong 2024 (RCT) | 130 patients undergoing paroxysmal AF ablation | Prospective, multi-center, randomized 1:1 to CPVI + SVCI (n = 50) vs. CPVI alone (n = 50) | In patients without provoked SVC triggers, SVCI, in addition to CPVI, did not increase freedom from atrial tachyarrhythmias (87.9 vs. 79.6%, log-rank p = 0.28) |
Crista terminalis (CT) | Dixit 2012 (RASTA study) | 156 patients with PeAF. Standard approach: PVI + ablation of non-PV triggers identified using a stimulation protocol | Single-center, randomized to either arm 1 (PVI + standard approach), arm 2, (standard approach + empirical ablation at common NPVTs (including CT)), or arm 3 (standard approach + ablation of LA CFAEs) | Freedom from AAs after single ablation was lowest with arm 3 (29%) vs. arm 1 (49%; p = 0.04) and arm 2 (58%; p = 0.004) |
Vein of Marshall (VOM) | Valderrábano 2020 (VENUS Randomized Clinical Trial) | 343 patients with PeAF | Single-blinded trial, randomized 1:1.15 to CA alone (n = 158) or CA + VOM ethanol infusion (n = 185) | Higher freedom from AF/atrial tachycardia with catheter ablation + VOM ethanol ablation vs. catheter ablation alone at 6 and 12 months (difference, 11.2% [95% CI, 0.8%–21.7%]; p = 0.04) |
Low voltage areas (LVAs) | Kaiser 2024 (RCT) | 100 patients with PeAF | Randomized 1:1 to A or B. A: PVI + substrate modification if LVAs present, B: PVI + additional ablation if AF persisted | Freedom from AAs in 34 (68%) patients of group A vs.28 (56%) patients in group B (p = ns). Low complication rate in both groups. |
Huo 2022 (RCT) | 324 patients with PeAF | Multicenter trial, randomized 1:1 to PVI alone (n = 163) vs. PVI + substrate modification (n = 161) | Lower first AA recurrence with PVI + substrate modification (35%) vs. PVI-only (50%) (Kaplan–Meier event rate estimates: HR = 0.62, 95% CI = 0.43 to 0.88, log-rank p = 0.006) |
Ablation Target | Study | Study Population | Outcome |
---|---|---|---|
Left atrial posterior wall (LAPW) | Kanitsoraphan et al., 2022 | 8 RCTs with 1024 patients with AF | Adjunctive PWI decreased AF recurrence compared to controlled approaches (RR 0.88, 95% CI: 0.81–0.96, I2 = 48.2%, p-value 0.004) without decrease in overall AA recurrence (RR 0.96, 95% CI: 0.88–1.05, I2 = 31.6%, p-value 0.393) |
Left atrial appendage (LAA) | Romero et al., 2018 | 7 studies that enrolled a total of 930 patients [mean age 63 ± 5 years; male: 69%]. | LAA ablation + standard ablation appears to improve freedom from AAs in patients with PeAF and long-standing PeAF without raising complication risks. [56% relative reduction and 31.6% absolute reduction; RR 0.44, 95% CI 0.31–0.64; p < 0.0001] |
Superior vena cava (SVC) | Sharma et al., 2017 | 3 RCTs with 526 participants with AF | No difference in AF recurrence rate between PVI + SVCI versus PVI alone (39% vs. 60%; OR 0.68; 95% CI 0.43–1.07; p = 0.73; I2 = 0%) |
Low voltage areas (LVAs) | Rivera et al., 2024 | 10 RCTs with 1780 patients with AF | Adjunctive LVA ablation significantly reduced recurrence of AA, as compared with conventional ablation (RR 0.76; 95% CI 0.67−0.88; p < 0.01) |
Toumpourleka et al., 2023 | 5 RCTs with 989 participants with PeAF | Higher probability for freedom from arrhythmia with additional LVA substrate modification when compared to conventional AF ablation (OR 1.73; 95% CI 1.03–2.90; I2 = 0%; p = 0.04). |
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Baqal, O.; Shafqat, A.; Kulthamrongsri, N.; Sanghavi, N.; Iyengar, S.K.; Vemulapalli, H.S.; El Masry, H.Z. Ablation Strategies for Persistent Atrial Fibrillation: Beyond the Pulmonary Veins. J. Clin. Med. 2024, 13, 5031. https://doi.org/10.3390/jcm13175031
Baqal O, Shafqat A, Kulthamrongsri N, Sanghavi N, Iyengar SK, Vemulapalli HS, El Masry HZ. Ablation Strategies for Persistent Atrial Fibrillation: Beyond the Pulmonary Veins. Journal of Clinical Medicine. 2024; 13(17):5031. https://doi.org/10.3390/jcm13175031
Chicago/Turabian StyleBaqal, Omar, Areez Shafqat, Narathorn Kulthamrongsri, Neysa Sanghavi, Shruti K. Iyengar, Hema S. Vemulapalli, and Hicham Z. El Masry. 2024. "Ablation Strategies for Persistent Atrial Fibrillation: Beyond the Pulmonary Veins" Journal of Clinical Medicine 13, no. 17: 5031. https://doi.org/10.3390/jcm13175031