Catheter ablation of long-standing persistent atrial fibrillation: a lesson from circumferential pulmonary vein isolation.

INTRODUCTION: Circumferential pulmonary vein isolation (CPVI) is associated with a high success rate in patients with paroxysmal and persistent atrial fibrillation (AF). However, in patients with long-standing persistent AF, the ideal ablation strategy still remains a matter of debate.

METHODS AND RESULTS: Two-hundred and five patients underwent catheter ablation for long-standing persistent AF defined as continuous AF of more than 1-year duration. In a first step, all patients underwent CPVI. If direct-current cardioversion failed following CPVI, ablation of complex fractionated atrial electrograms (CFAEs) was performed. The goal was conversion into sinus rhythm (SR) or, alternatively, atrial tachycardia (AT) with subsequent ablation. A total of 340 procedures were performed. CPVI alone was performed during 165 procedures in 124 of 205 (60.5%) patients. In the remaining 81 patients, additional CFAE ablation was performed in 45, left linear lesions for recurrent ATs in 44 and SVC isolation in 15 patients, respectively, resulting in inadvertent left atrial appendage isolation in 9 (4.4%) patients. After the initial ablation procedure, 67 of 199 patients remained in SR during a mean follow-up of 19 ± 11 months. Six patients were lost to follow-up. After a mean of 1.7 ± 0.8 procedures, 135 of 199 patients (67.8%) remained in SR. Eighty-six patients (43.2%) remained in SR following CPVI performed as the sole ablative strategy.

CONCLUSIONS: CPVI alone is sufficient to restore SR in 43.2% of patients with long-standing persistent AF. Multiple procedures and additional ablation strategies with a significant risk of inadvertent left atrial appendage isolation are often required to maintain stable SR.