Rotor-guided tailor-made pulmonary vein isolation for persistent atrial fibrillation: Identification of the left atrial septum as a common arrhythmogenic substrate.

BACKGROUND

In patients with persistent atrial fibrillation (AF), additional substrate modification beyond pulmonary vein isolation (PVI) is controversial, given limited durability and increased atrial tachycardias (ATs). ExTRa Mapping system is a new tool to clarify the real-time imaging of AF rotors.

OBJECTIVE

We evaluated the efficacy of extended PVI that combines cryoballoon PVI with tailor-made radiofrequency (RF) ablation of pulmonary vein antrum rotors identified by ExTRa Mapping.

METHODS

58 patients with persistent AF underwent initial ablation using a tailored strategy: cryoballoon PVI followed by RF line extension to encompass adjacent AF rotors identified by ExTRa Mapping (rotor-guided extended PVI group). Outcomes were compared with 2 contemporaneous control groups: (1) cryoballoon PVI alone (PVI-alone group, n = 33) and (2) RF-based PVI plus posterior wall isolation (PWI) (PVI + PWI group, n = 43). The primary endpoint was freedom from AF/AT recurrence without antiarrhythmic drugs at 12 months.

RESULTS

Baseline characteristics were comparable among groups. Left atrial septal Nonpassively activated areas were observed in 70.7% of patients and were the most common location. Accordingly, in the rotor-guided extended PVI group, anterior extension from the right pulmonary vein toward the left atrial septal rotor was the most frequently applied strategy. At 12 months, freedom from AF/AT was significantly higher in the rotor-guided extended PVI group (89.7%) than the PVI-alone group (63.6%) and the PVI + PWI group (65.1%) (log-rank P = .004). In multivariable Cox analysis, the rotor-guided extended PVI strategy was independently associated with a lower risk of AF/AT recurrence.

CONCLUSION

Cryoballoon PVI combined with ExTRa Mapping-guided RF ablation targeting adjacent rotors improves arrhythmia outcomes without increasing ATs.