A randomized trial of circumferential pulmonary vein ablation versus antiarrhythmic drug therapy in paroxysmal atrial fibrillation: the APAF Study. A Randomized Controlled Trial of the Efficacy and Safety of Electroanatomic Circumferential Pulmonary Vein Ablation Supplemented by Ablation of Complex Fractionated Atrial Electrograms Versus Potential-Guided Pulmonary Vein Antrum Isolation Guided by Intracardiac Ultrasound Selective segmental ostial ablation and circumferential pulmonary veins ablation. Results of an individualized strategy to cure refractory atrial fibrillation Symptomatic and asymptomatic atrial fibrillation after pulmonary vein ablation and the impact on quality of life. Prophylactic cavotricuspid isthmus block during atrial fibrillation ablation in patients without atrial flutter: a randomised controlled trial A randomized clinical trial of early invasive intervention for atrial fibrillation (EARLY-AF) - methods and rationale. Randomized Ablation Strategies for the Treatment of Persistent Atrial Fibrillation: RASTA Study Circumferential pulmonary vein ablation: does use of a circular mapping catheter improve results? A prospective randomized study. Randomized comparison between pulmonary vein antral isolation versus complex fractionated electrogram ablation for paroxysmal atrial fibrillation. Antiarrhythmic drug therapy after radiofrequency catheter ablation in patients with atrial fibrillation. Catheter ablation of atrial fibrillation in patients with diabetes mellitus type 2: results from a randomized study comparing pulmonary vein isolation versus antiarrhythmic drug therapy. Circumferential Pulmonary Vein Ablation With Additional Linear Ablation Results in an Increased Incidence of Left Atrial Flutter Compared With Segmental Pulmonary Vein Isolation as an Initial Approach to Ablation of Paroxysmal Atrial Fibrillation Single procedure efficacy of isolating all versus arrhythmogenic pulmonary veins on long-term control of atrial fibrillation: a prospective randomized study. Circumferential pulmonary vein isolation as index procedure for persistent atrial fibrillation: a comparison between radiofrequency catheter ablation and second-generation cryoballoon ablation. Left Atrial Posterior Wall Isolation Does Not Improve the Outcome of Circumferential Pulmonary Vein Ablation for Atrial Fibrillation: A Prospective Randomized Study Prevention of Iatrogenic Atrial Tachycardia After Ablation of Atrial Fibrillation: A Prospective Randomized Study Comparing Circumferential Pulmonary Vein Ablation With a Modified Approach Ablation for longstanding permanent atrial fibrillation: results from a randomized study comparing three different strategies.
OBJECTIVES We compared ablation strategy with antiarrhythmic drug therapy ( ADT ) in patients with paroxysmal atrial fibrillation ( PAF ) . BACKGROUND Atrial fibrillation ( AF ) ablation strategy is superior to ADT in patients with an initial history of PAF , but its role in patients with a long history of AF as compared with ADT remains a challenge . METHODS One hundred ninety-eight patients ( age , 56 + /- 10 years ) with PAF of 6 + /- 5 years ' duration ( mean AF episodes 3.4/month ) who had failed ADT were r and omized to AF ablation by circumferential pulmonary vein ablation ( CPVA ) or to the maximum tolerable doses of another ADT , which included flecainide , sotalol , and amiodarone . Crossover to CPVA was allowed after 3 months of ADT . RESULTS By Kaplan-Meier analysis , 86 % of patients in the CPVA group and 22 % of those in the ADT group who did not require a second ADT were free from recurrent atrial tachyarrhythmias ( AT ) ( p < 0.001 ) ; a repeat ablation was performed in 9 % of patients in the CPVA group for recurrent AF ( 6 % ) or atrial tachycardia ( 3 % ) . At 1 year , 93 % and 35 % of the CPVA and ADT groups , respectively , were AT-free . Ejection fraction , hypertension , and age independently predicted AF recurrences in the ADT group . Circumferential pulmonary vein ablation was associated with fewer cardiovascular hospitalizations ( p < 0.01 ) . One transient ischemic attack and 1 pericardial effusion occurred in the CPVA group ; side effects of ADT were observed in 23 patients . CONCLUSIONS Circumferential pulmonary vein ablation is more successful than ADT for prevention of PAF with few complications . Atrial fibrillation ablation warrants consideration in selected patients in whom ADT had already failed and maintenance of sinus rhythm is desired . ( A Controlled R and omized Trial of CPVA Versus Antiarrhythmic Drug Therapy in for Paroxysmal AF : APAF/01 ; http:// clinical trials.gov/ct/show ; NCT00340314 ) Background —The study was conducted to compare relative safety and efficacy of pulmonary vein antrum isolation ( PVAI ) using intracardiac echocardiographic guidance and circumferential pulmonary vein ablation ( CPVA ) for atrial fibrillation ( AF ) using radiofrequency energy . Methods and Results —Sixty patients ( 81 % men ; 81 % paroxysmal ; age , 56±8 years ) failing 2±1 antiarrhythmic drugs were r and omly assigned to undergo CPVA ( n=30 ) or PVAI ( n=30 ) at 5 centers between December 2004 and October 2007 .  CPVA patients had circular lesions placed at least 1 cm outside of the veins . Ipsilateral veins were ablated en block with the end point of disappearance of potentials within the circular lesion . Left atrial roof line and mitral isthmus line were ablated without verification of block . For patients in AF postablation or with AF induced with programmed stimulation , complex fractionated electrograms were mapped and ablated to the end point of AF termination or disappearance of complex fractionated electrograms . PVAI did not include complex fractionated electrogram ablation . Esophageal temperature was monitored and kept within 2 ° C of baseline or under 39 ° C . Success was defined as absence of atrial tachyarrhythmias ( AF/AT ) off antiarrhythmic drugs . There was no difference between CPVA and PVAI regarding to baseline variables , catheter used , duration of the procedure , or RF delivery . Fluoroscopy time was longer with PVAI ( 54±17 minutes versus 77±18 minutes , P=0.0001 ) . No significant complications occurred in either arm . PVAI was more likely to achieve control of AF/AT off antiarrhythmic drugs ( 57 % versus 27 % , P=0.02 ) at 2±1 years of follow-up . Conclusions —A single PVAI procedure is more likely to result in freedom from AF/AT off antiarrhythmic drugs than CPVA supplemented by complex fractionated electrogram ablation in select patients Aims Previous studies have analyzed the efficacy of atrial fibrillation (  AF )  ablation in series of consecutive patients or comparing methods in a r and omized way , without taking account individual patient characteristics . The purpose of this study was to evaluate the results of a strategy based on selecting the ablation method according to patient clinical features in drug-refractory paroxysmal or persistent AF . Methods and results Patients with left atrial diameter ≤40 mm and runs of atrial tachycardia of more than ten beats during Holter recording were selected for selective segmental ostial ablation ( SSOA ) in order to disconnect only those pulmonary veins with electrical potentials . The remaining patients underwent circumferential pulmonary veins ablation ( CPVA ) to modify left atrial substrate by extensive linear lesions . A group of 131 consecutive patients were included . Mean follow-up was 21.5 ± 15.2 months . In paroxysmal AF , 44 and 55 patients were selected for SSOA and CPVA , respectively , and the efficacy of the procedure was similar in the two groups ( 77 vs 74 % ; log-rank test p = NS ) . In persistent AF , 6 and 26 patients underwent SSOA and CPVA , respectively , and greater efficacy was observed in the second group ( 17 vs 65 % ; log-rank test p = 0.004 ) . Conclusions Selecting the ablation method according to patient characteristics achieved good results and reduced the overall amount of ablated atrial tissue in patients with paroxysmal AF . However , in persistent AF the SSOA technique showed very limited efficacy despite the previous patient selection and a CPVA-like procedure may be the appropriate choice in all cases BACKGROUND The aim of this prospect i ve study was to evaluate the recurrences of atrial fibrillation ( AF ) and flutter ( AFL ) after circumferential pulmonary vein ablation ( CPVA )  using repetitive long-term Holter recordings , and to evaluate the change in quality of life ( QoL ) , especially in patients with asymptomatic AF recurrences . METHODS A total of 149 patients with AF were followed up with 7-day Holter monitoring at 3 , 6 , and 12 months after CPVA .  We calculated the burden of AF/AFL defined as the percentage of time in AF/AFL , and patients with documented arrhythmia were divided into isolated symptomatic episodes of arrhythmia , mixed symptomatic/asymptomatic arrhythmia , or isolated asymptomatic arrhythmia . The QoL was analyzed with SF-36 question naires in patients with sinus rhythm after CPVA , and in patients with recurrence of symptomatic and asymptomatic arrhythmia , respectively . RESULTS Asymptomatic arrhythmia was observed in 44 % of the patients with documented arrhythmia at 12 months of follow-up . In patients with persistent AF , 63 % of the documented arrhythmia at 12 months of follow-up was asymptomatic and often persistent . In the subgroup of patients with asymptomatic arrhythmia , the QoL improved significantly in the physical scores , in contrast to patients with symptomatic arrhythmia who had unchanged or worsened QoL scores . CONCLUSIONS Asymptomatic arrhythmia is very common after AF ablation . Our data indicate that these patients improve their physical component of the QoL significantly , which may be considered a palliative success of treatment . We suggest that patients with asymptomatic AF recurrences are carefully evaluated before considering reablation . Repetitive rhythm monitoring after AF ablation is very important considering the postablation management of anticoagulant therapy Objectives : This r and omised trial evaluated if patients with atrial fibrillation ( AF ) and no history of atrial flutter ( AFL ) had any benefit of prophylactic cavotricuspid isthmus block ( CTIB ) in addition to circumferential pulmonary vein ablation ( CPVA ) . Methods : 149 patients with AF ( 54 % paroxysmal ) were r and omised to CPVA and CTIB  ( group CTIB+ , n = 73 ) or  CPVA alone  ( group CTIB− , n = 76 ) . Patients were followed for 12 months with repetitive 7-day Holter monitoring after 3 , 6 and 12 months . Results : Six patients ( 4 % ) had cardiac tamponade , and one patient had a stroke . No difference was found in the cumulative AFL-free rate between the two treatment groups ( CTIB+ : 88 % vs CTIB− : 84 % , hazard ratio ( HR ) 0.80 , 95 % CI ( 0.34 to 1.90 ) , p = 0.61 ) . There was no difference in the cumulative AF-free rate between the groups ( CTIB+ : 34 % vs CTIB− : 32 % , HR 0.93 , 95 % CI ( 0.63 to 1.38 ) , p = 0.71 ) . Overall , 33 % of the patients were free of AF after a single procedure . Including re procedures , a complete or partial beneficial effect was noted in 62 % of the patients at 12 months . At 12-month follow-up , 24 ( 50 % ) patients with documented AF or AFL in the Holter recordings were asymptomatic . Conclusions : It was not possible to demonstrate any beneficial effect of CTIB in addition to CPVA with regard to AFL or AF recurrences during follow-up . Repetitive long-term Holter monitoring demonstrated a 33 % rate of freedom from AF during a 1-year follow-up . Including additional CPVA procedures , a clinical effect was noted in 62 % of the patients at 12 months . Patients with AF or AFL recurrences were often asymptomatic BACKGROUND The ideal management of patients with newly diagnosed symptomatic atrial fibrillation ( AF ) remains unknown . Current practice guidelines recommend a trial of antiarrhythmic drugs ( AAD ) prior to considering an invasive ablation procedure . However , earlier ablation offers an opportunity to halt the progressive patho-anatomical changes associated with AF , as well as impart other important clinical benefits . OBJECTIVE The aim of this study is to determine the optimal initial management strategy for patients with newly diagnosed , symptomatic atrial fibrillation . METHODS / DESIGN The EARLY-AF study ( Clinical Trials.govNCT02825979 ) is a prospect i ve , open label , multicenter , r and omized trial with a blinded assessment of outcomes . A total of 298 patients will be r and omized in a 1:1 fashion to first-line AAD therapy , or first-line cryoballoon-based pulmonary vein isolation .  Patients with symptomatic treatment naïve AF will be included . Arrhythmia outcomes will be assessed by implantable cardiac monitor ( ICM ) . The primary outcome is time to first recurrence of AF , atrial flutter , or atrial tachycardia ( AF/AFL/AT ) between days 91 and 365 following AAD initiation or AF ablation . Secondary outcomes include arrhythmia burden , quality of life , and healthcare utilization . DISCUSSION The EARLY-AF study is a r and omized trial design ed to evaluate the optimal first management approach for patients with AF . We hypothesize that catheter ablation will be superior to drug therapy in prevention of AF recurrence Background — The single-procedure efficacy of pulmonary vein isolation ( PVI ) is less than optimal in patients with persistent atrial fibrillation ( AF ) . Adjunctive techniques have been developed to enhance single-procedure efficacy in these patients . We conducted a study to compare 3 ablation strategies in patients with persistent AF . Methods and Results — Subjects were r and omized as follows : arm 1 , PVI + ablation of non-PV triggers identified using a stimulation protocol ( st and ard approach ) ; arm 2 , st and ard approach + empirical ablation at common non-PV AF trigger sites ( mitral annulus , fossa ovalis , eustachian ridge , crista terminalis , and superior vena cava ) ; or arm 3 , st and ard approach + ablation of left atrial complex fractionated electrogram sites . Patients were seen at 6 weeks , 6 months , and 1 year ; transtelephonic monitoring was performed at each visit . Antiarrhythmic drugs were discontinued at 3 to 6 months . The primary study end point was freedom from atrial arrhythmias off antiarrhythmic drugs at 1 year after a single-ablation procedure . A total of 156 patients ( aged 59±9 years ; 136 males ; AF duration , 47±50 months ) participated ( arm 1 , 55 patients ; arm 2 , 50 patients ; arm 3 , 51 patients ) . Procedural outcomes ( procedure , fluoroscopy , and PVI times ) were comparable between the 3 arms . More lesions were required to target non-PV trigger sites than a complex fractionated electrogram ( 33±9 versus 22±9 ; P<0.001 ) . The primary end point was achieved in 71 patients and was worse in arm 3 ( 29 % ) compared with arm 1 ( 49 % ; P=0.04 ) and arm 2 ( 58 % ; P=0.004 ) . Conclusions — These data suggest that additional substrate modification beyond PVI does not improve single-procedure efficacy in patients with persistent AF . Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT00379301 BACKGROUND The best method for performing atrial fibrillation ( AF ) ablation is still under debate . The importance of using a circular mapping ( CM ) catheter for assessing isolation of the pulmonary vein ( PV ) antrum on the outcome of the procedure has not been clearly established . OBJECTIVE The purpose of this study was to evaluate whether use of a CM catheter improves the arrhythmia-free proportion after circumferential pulmonary vein ablation ( CPVA ) . METHODS A series of 146 consecutive patients ( 83 % males , age 53 + /- 10 years , 53 % paroxysmal AF ) were r and omized to two ablation strategies . In both groups , ipsilateral PV encirclement was performed until disappearance or dissociation of the local electrogram within the surrounded area . In the first group , only the radiofrequency catheter was used to both map and ablate ( CPVA group , n = 73 ) . In the other group , a CM catheter was added to assess the electrical activity of the PV antrum ( CPVA-CM group , n = 73 ) . An ablation line along the left atrial roof was also created in all patients . RESULTS Procedural and fluoroscopic times were longer in the CPVA-CM group ( P < .05 ) . Severe procedure-related complications occurred in 1 ( 1.4 % ) patient in the CPVA group and in 3 ( 4.1 % ) patients in the CPVA-CM group ( P = .317 ) . After mean follow-up of 9 + /- 3 months , 31 ( 42.5 % ) patients in the CPVA group and 47 ( 64.4 % ) patients in the CPVA-CM group were arrhythmia-free without antiarrhythmic medication ( P = .008 ) . CONCLUSION Use of a CM catheter to ensure isolation of the PV antrum improved the success of CPVA but increased some procedural requirements INTRODUCTION Circumferential pulmonary vein antral isolation ( PVAI ) and atrial complex fractionated electrograms ( CFEs ) are both ablative techniques for the treatment of paroxysmal atrial fibrillation ( PAF ) . However , data on the comparative value of these 2 ablation strategies are very limited . METHODS AND RESULTS We r and omized 118 patients with drug-refractory PAF to receive  PVAI ablation ( n = 60 ) or CFE ablation ( n = 58 ) . For CFE group , spontaneous/induced AF was mapped using vali date d , automated software to guide ablation until all CFE areas were eliminated . For PVAI group , all 4 pulmonary vein antra were electrically isolated as confirmed by circular mapping catheter . Patients with spontaneous/inducible AF after the initial ablation procedure were crossed over to the other arms . After initial ablation procedure , AF persisted/inducible in 24/59 patients ( 41 % ) , and 34/58 patients ( 59 % ) assigned to PVAI and CFE ablation , respectively ( P = 0.05 ) . Then 58 patients underwent PVAI + CFE ablation . After 22.6 ± 6.4 months , PVAI ablation group was more likely than CFE ablation group to achieve control of any AF/atrial tachycardia ( AT ) off drugs ( 43/60 , 72 % vs 33/58 , 57 % , P = 0.075 ) and lower recurrence rate of AT ( 11.9 % vs 34.5 % , P = 0.004 ) . Patients who received CFE ablation alone ( 38 % ) had significantly lower overall success rate to achieve control of AF/AT off drugs compared with patients who received PVAI ablation ( 77 % , P = 0.002 ) alone or PVAI + CFE ablation ( 69 % , P = 0.008 ) due to higher recurrence rate of AT ( 50 % vs 6 % vs 13 % , P < 0.01 ) . CONCLUSIONS CFE ablation in PAF patients was associated with higher occurrence rate of postprocedure AT compared with PVAI ablation , whereby making it less likely to be a sole ablation strategy for PAF patients OBJECTIVES The use of antiarrhythmic drugs after ablation is a controversial issue when evaluating the efficacy of atrial fibrillation ( AF ) ablation . This study compares in a prospect i ve and r and omized fashion the impact of an antiarrhythmic drug in preventing AF recurrence after AF ablation . METHODS From February 2004 to May 2005 , 107 consecutive patients ( mean age 57 + /- 10 years , 69 men ) , with paroxysmal ( 60 % ) or persistent ( 40 % ) drug refractory AF , were r and omly assigned to ablation alone ( Group A , 53 patients ) or combined with the best antiarrhythmic therapy , preferably amiodarone ( Group B , 54 patients ) . All patients underwent cavo-tricuspid and left inferior pulmonary vein (PV)-mitral isthmus ablation plus circumferential PV ablation , using a guided electro-anatomical approach . St and ard electrocardiograms ( ECG ) , and ambulatory and transtelephonic ECG monitoring  were used to assess AF recurrences . Recurrences during the first month after ablation were excluded from this analysis . RESULTS At 12 months of follow-up , no significant difference was observed in the rates of AF recurrences between Group A ( 18/53 patients , 34 % ) and Group B ( 16/54 patients , 30 % ) . The percentage of patients with > /= 1 asymptomatic AF episode was higher in Group B than in Group A ( 10/16 patients , 63 % , vs 5/18 patients , 28 % , P = 0.04 ) . CONCLUSIONS Continuing antiarrhythmic drug therapy in patients who undergo catheter ablation for AF did not lower the rate of AF recurrences . Antiarrhythmic drugs increased the proportion of patients with asymptomatic AF episodes INTRODUCTION Atrial fibrillation ( AF ) and diabetes mellitus type 2 ( DM2 ) often coexist ; however , a small number of patients with DM2 undergoing catheter ablation ( CA ) of AF  have been included in previous studies . The aim of this study was to evaluate safety and efficacy of ablation therapy in DM2 patients with drug refractory AF . METHODS AND RESULTS From January 2005 to September 2006 , 70 patients with a diagnosis of DM2 and paroxysmal ( n = 29 ) or persistent ( n = 41 ) AF were r and omized to receive either pulmonary vein isolation or a new antiarrhythmic drug treatment ( ADT ) with a 1-year follow-up . The primary endpoint was the time to first AF recurrence . By Kaplan-Meier analysis , at the end of follow-up , 42.9 % of patients in the ADT group and 80 % of patients who received a single ablation procedure and were without medications were free of AF ( P = 0.001 ) . In the ablation group , a significant improvement in quality -of-life ( QoL ) scores as compared with ADT group was observed . Six patients in the ADT group ( 17.1 % ) developed significant adverse drug effects . Hospitalization rate during follow-up was higher in the ADT group ( P = 0.01 ) . The only complication attributable to ablation was one significant access-site hematoma . CONCLUSION In patients with DM2 , CA of AF provides significant clinical benefits over the ADT and appears to be a reasonable approach regarding feasibility , effectiveness , and low procedural risk Background —There has been growing concern that linear ablation is associated with an increased risk of iatrogenic arrhythmias in patients undergoing ablation for atrial fibrillation ( AF ) . Therefore , we compared circumferential pulmonary vein ablation plus left atrial linear ablation ( CPVA+LALA ) with segmental pulmonary vein isolation (PVI)in  patients with paroxysmal AF . Methods and Results —Sixty-six consecutive patients with paroxysmal AF were prospect ively r and omly assigned to receive PVI versus CPVA+LALA ( consisting of encircling lesions around the pulmonary veins ) , a roof line , and a mitral isthmus line with documentation of bidirectional mitral isthmus block . All patients were seen at 1 , 3 , 6 , and every 12 months after ablation , with 14-day continuous ECG monitoring every 6 months . At 16.4±6.3 months after 1 ablation procedure , 19 patients ( 58 % ) remained free of atrial arrhythmias after PVI versus 17 patients ( 51 % ) after CPVA+LALA ( P=0.62 ) . After PVI , 14 patients had recurrent paroxysmal AF , whereas after CPVA+LALA , 8 patients had recurrent AF , 6 had atypical left atrial flutter ( LAFL ) , and 2 had both AF and LAFL ( P=0.32 between PVI versus CPVA+LALA for AF but P=0.002 for LAFL ) . Twenty-eight patients ( 85 % ) remained arrhythmia-free after 1.3±0.5 PVI procedures versus 28 patients ( 85 % ) after 1.4±0.6 CPVA+LALA procedures ( P = NS ) . Fluoroscopy time was longer after CPVA+LALA versus PVI ( 91 versus 73 minutes , P=0.04 ) . Conclusions —As an initial ablation approach in patients with paroxysmal AF  , more LAFL occurred after CPVA+LALA and fluoroscopy times were longer compared with segmental PVI BACKGROUND Current atrial fibrillation ( AF ) ablation involves isolation of all pulmonary veins ( PVs ) with or without additional linear lesions . However , whether such extensive ablation is necessary is unclear . OBJECTIVE The purpose of this study was to assess the efficacy of different ablation strategies on long-term AF control . METHODS We prospect ively r and omized patients to undergo isolation of all versus arrhythmogenic PVs ( identified by st and ardized stimulation protocol ) .  PV isolation was guided by circular mapping catheter . The endpoint was entry/exit block persisting for > or = 20 minutes . Patients were evaluated at three clinic visits ( at 6 weeks , 6 months , and 1 year ) and multiple transtelephonic monitoring periods . Antiarrhythmic drugs were discontinued at 6 weeks . Primary study endpoint was long-term AF control ( freedom or > 90 % reduction in AF burden off or on previously ineffective antiarrhythmic drugs at 1 year after a single ablation procedure ) . RESULTS Over a 20-month period , 105 patients ( 76 men and 29 women , age 57 + /- 9 years ; paroxysmal AF = 77 ) were r and omized , and 103 patients completed 1-year follow-up ( 51 patients in all-PV arm , 52 patients in arrhythmogenic PV arm ) . The primary endpoint was achieved in 75 ( 73 % ) patients and was similar in patients r and omized to all-PV arm versus arrhythmogenic PV arm [ 38 ( 75 % ) patients vs 37 ( 71 % ) patients , respectively ; odds ratio 1.18 , 95 % confidence interval 0.50 , 2.83 , P = .70 ] . Secondary study endpoints , including freedom from AF off antiarrhythmic drugs , total procedure/fluoroscopy times , and occurrence of serious adverse events , were not different between the two groups . CONCLUSION In a r and omized comparison , isolation of arrhythmogenic veins was as efficacious as empiric isolation of all veins in achieving long-term AF control AIMS To assess the 1 year efficacy of pulmonary vein isolation ( PVI ) as index procedure for persistent atrial fibrillation ( PersAF ) comparing conventional radiofrequency irrigated-tip catheter ablation ( RFCA ) using contact-force technology and ablation using the second-generation cryoballoon ( CB-AdvA ) . METHODS AND RESULTS One hundred consecutive patients ( 74 male , 74 % ; mean age 62.4 ± 9.6 years ) with drug-refractory PersAF undergoing PVI using RFCA and CB-AdvA were enrolled . Follow-up was based on outpatient clinic visits including Holter-electrocardiograms . Recurrence of atrial tachyarrhythmias ( ATas ) was defined as a symptomatic or documented episode > 30 s. Among 100 patients , 50 underwent RFCA whereas 50 CB-AdvA.  Mean procedure and fluoroscopy times were 90.5 ± 41.7 vs. 140.2 ± 46.9 min and 14.5 ± 6.6 vs. 19.8 ± 6.8 min in the CB-Adv and in the RFCA group , respectively ( P < 0.01 ) . At 1 year follow-up , after a 3 months blanking period ( BP ) , freedom from ATas off-drugs after a single procedure was 60 % ( 28/50 patients ) in the CB-Adv and 56 % ( 27/50 patients ) in the RFCA group ( P = 0.71 ) . Multivariate analysis demonstrated that PersAF duration ( P = 0.01 ) and relapses during BP ( P = 0.02 ) were independent predictors of ATa recurrences following the index procedure . CONCLUSION Freedom from ATas following PersAF ablation with RFCA and CB-Adv is comparable at 1 year follow-up after a single procedure . Ablation with the CB-Adv is associated with shorter procedure time and radiation exposure as compared with RFCA . Atrial tachyarrhythmias occurrence during BP and longer time of PersAF seem to be significant predictors of arrhythmia recurrences after the index procedure Background —Ablation of the pulmonary veins ( PVs ) for atrial fibrillation treatment is often combined with linear radiofrequency lesions along the left atrium ( LA ) to improve the success rate . The study was design ed to assess the contribution of LA posterior wall isolation to the outcome of circumferential pulmonary vein ablation ( CPVA ) . Methods and Results —CPVA consisted of continuous radiofrequency lesions encircling both ipsilateral PVs plus an ablation line along the mitral isthmus . Patients were then r and omized into 2 groups . In the first group , superior PVs were connected by linear lesions along the LA roof ( CPVA-1 group ) . In the second group , the LA posterior wall was isolated by adding a second line connecting the inferior aspect of the 2 inferior PVs ( CPVA-2 group ) . The study included 120 patients ( 53±11 years , 77 % male , 60 % paroxysmal atrial fibrillation , LA of 41.3±5.4 mm , 46 % with hypertension , and 22 % with structural heart disease ) . After a single ablation procedure and a mean follow-up of 10±4 months , 24 ( 40 % ) patients of the CPVA-1 group had atrial fibrillation recurrences and 3 ( 5 % ) had new-onset LA flutter . In the CPVA-2  group , recurrences were due to atrial fibrillation episodes in 23 patients ( 38 % ) and LA flutter in 4 ( 7 % ) . Freedom from arrhythmia recurrences was not statistically different in the CPVA-1 group as compared with the CPVA-2 group ( log rank P=0.943 ) . Conclusion —Isolation of the LA posterior wall did not increase the success rate of CPVA Background —Circumferential pulmonary vein ablation ( CPVA ) is effective in curing  atrial fibrillation ( AF ) , but new-onset left atrial tachycardia ( AT ) is a potential complication . We evaluated whether a modified CPVA approach including additional ablation lines on posterior wall and the mitral isthmus would reduce the incidence of AT after PV ablation . Methods and Results —A total of 560 patients ( 291 men , 52 % ; age , 56.5±7.3 years ) entered the study ; 280 were r and omized to CPVA alone ( group 1 ) and 280 to modified CPVA ( group 2 ) . The primary end point was freedom from AT after the procedure . In group 1 , 28 patients ( 10 % ) experienced new-onset AT , and 41 ( 14.3 % ) experienced recurrent AF . In group 2 , 11 patients ( 3.9 % ) experienced AT , and 36 ( 12.9 % ) had recurrent AF . Group 1 was more likely to experience AT than group 2 ( P=0.005 ) . Freedom from AF after ablation was similar in both groups ( P=0.57 ) . Among those in group 1 , gap-related macroreentrant AT was documented in 23 of the 28 patients ( 82 % ) , and focal AT was found in 5 ( 18 % ) . In group 2 , gap-related macroreentrant AT was found in 8 of the 11 patients ( 73 % ) , and focal AT was seen in 3 ( 27 % ) . Two patients in group 1 and 1 patient in group 2 had both AT and AF . The strongest predictor of AT was the presence of gaps ( P<0.001 ) . Conclusions —Modified CPVA is as effective as CPVA in preventing AF but is associated with a lower risk of developing incessant AT BACKGROUND This prospect i ve multicenter r and omized study aim ed to compare the efficacy of 3 common ablation methods used for longst and ing permanent atrial fibrillation ( AF ) . METHODS A total of 144 patients with longst and ing permanent AF ( median duration 28 months ) were r and omly assigned to circumferential pulmonary vein ablation ( CPVA , group 1 , n = 47 ) , to pulmonary vein antrum isolation ( PVAI , group 2 , n = 48 ) or to a hybrid strategy combining ablation of complex fractionated or rapid atrial electrograms ( CFAE ) in both atria followed by a pulmonary vein antrum isolation ( CFAE + PVAI , group 3 , n = 49 ) . RESULTS Scarring in the left atrium and structural heart disease/hypertension were present in most patients ( 65 % ) . After a mean follow-up of 16 months , 11 % of patients in group 1 , 40 % of patients in group 2 and 61 % of patients in group 3 were in sinus rhythm after one procedure and with no antiarrhythmic drugs ( P < .001 ) . Sinus rhythm maintenance would increase respectively to 28 % ( group 1 ) , 83 % ( group 2 ) , and 94 % ( group 3 ) after 2 procedures and with antiarrhythmic drugs ( AADs , P < .001 ) . The AF terminated during ablation , either by conversion to sinus rhythm or organization into an atrial tachyarrhythmia , in 13 % of patients ( group 1 ) , 44 % ( group 2 ) , and 74 % ( group 3 ) respectively . CFAE alone , performed as the first step of the ablation in group 3 , organized AF in only 1 patient . CONCLUSION In this study , the hybrid AF ablation strategy including antrum isolation and CFAE ablation had the highest likelihood of maintaining sinus rhythm in patients with longst and ing permanent AF . Electrical isolation of the PVs , although inadequate if performed alone , is relevant to achieve long-term sinus rhythm maintenance after ablation . Bi-atrial CFAE ablation had a minimal impact on AF termination during ablation
We observed statistically significantly better AT recurrence-free survival with CPVA than with ADT .
BACKGROUND Circumferential pulmonary vein ablation ( CPVA ) has become common therapy for atrial fibrillation ( AF ) , but results of large r and omized controlled trials comparing this procedure with antiarrhythmic drug therapy ( ADT ) have not been published to date .
We conducted a systematic literature review to assess whether CPVA is superior to ADT for the management of AF .