Effectiveness of stratified anatomical ablation ("BCXL") for persistent atrial fibrillation: a retrospective cohort study.

BACKGROUND: Radiofrequency ablation is the cornerstone treatment for persistent atrial fibrillation (AF); however, outcomes of pulmonary vein isolation (PVI) alone remain unsatisfactory. OBJECTIVES: We aimed to assess a personalized stratified anatomical ablation strategy for persistent AF by comparing the effectiveness of BCXL (BC: extensive encircling PVI [EEPVI]; XL: stratified linear ablation based on left atrial substrate) with that of PVI. METHODS: We retrospectively analyzed data from patients with persistent AF undergoing radiofrequency ablation at Xinqiao Hospital between 2017 and 2021. Patients were stratified into BCXL and PVI groups. The follow-up period was 24 months. The primary endpoint was the documented recurrence of atrial arrhythmia lasting ≥ 30 s after a 3-month blanking period. RESULTS: The study included 244 patients (BCXL group, n = 159; PVI group, n = 85). The ablation success rate at 24 months was significantly higher in the BCXL group than in the PVI group (80.4% vs. 63.8%, p = 0.006). Specifically, intermediate- to high-risk patients (CAAP-AF score > 5) in the BCXL group achieved a higher success rate than those in the PVI group (76.8% vs. 59.6%, p = 0.032). After adjusting for confounding factors (CAAP-AF score, left atrial low-voltage zone, age, sex, and body mass index), stratified anatomical ablation remained an independent predictor of ablation success (OR: 3.513; 95% CI: 1.725–7.154; p = 0.001). CONCLUSION: A personalized stratified anatomical ablation strategy improves radiofrequency ablation outcomes, particularly in patients with intermediate- to high-risk AF.