Catheter ablation of long-lasting persistent atrial fibrillation: Clinical outcome and mechanisms of subsequent arrhythmias

Background: Catheter ablation of atrial fibrillation (AF) is challenging in patients with long-standing persistent AF. The clinical outcome and subsequent arrhythmia recurrence after using an ablation method targeting multiple left atrial sites with the aim of achieving acute AF termination has not been characterized. Methods: Sixty patients (mean age: 53 ± 9 years) with persistent AF (mean duration: 17 ± 27 months) were prospectively followed after catheter ablation. Catheter ablation targeting the following sites was performed in a random sequence: (i) electrical isolation of all pulmonary veins (PV); (ii) disconnection of other thoracic veins; (iii) atrial ablation at sites possessing complex electrical activity, activation gradients, or short cycle lengths. Finally, linear ablation of the LA roof and mitral isthmus was performed if sinus rhythm was not restored following energy delivery to the above sites. At 1, 3, 6, and 12 months after ablation, patients underwent clinical review and 24-hour ambulatory ECG monitoring to identify asymptomatic arrhythmia. Repeat mapping and catheter ablation was performed in any patient experiencing recurrent atrial tachycardia (AT). Clinical success was defined as the absence of any sustained atrial arrhythmia. Results: AF terminated during ablation in 52 patients (87%). The fluoroscopy and procedural durations were 84 ± 30 minutes and 264 ± 77 minutes, respectively. Three months after ablation, sustained ATs were documented in 24 patients (associated with AF in 2). Mapping in 23 patients showed a single AT in 7 while multiple ATs were observed in 16. Macroreentry was confirmed to be due to gaps in the ablation lines, while focal ATs originated from discrete sites or isthmuses near the left atrial appendage, coronary sinus, pulmonary veins, or fossa ovalis; these sites were similar to those at which the greatest impact was observed on the fibrillatory process during the initial ablation procedure. After repeat ablation, at 11 ± 6 months of follow-up, 57 patients (95%) were in sinus rhythm and 3 developed recurrent AF or AT. All patients in sinus rhythm demonstrated improved exercise capacity and all but 2 had evidence of atrial transport as assessed by Doppler echocardiography (mitral A wave velocity 34 ± 17 cm/sec) by 6 months. Conclusion: Catheter ablation of long-lasting persistent AF associated with acute AF termination achieves medium to long-term restoration and maintenance of sinus rhythm in 95% of patients. Arrhythmia recurrence in the majority of patients is AT.