Clinical Outcomes of High Density Voltage and Fractionation Mapping-Guided Ablation in Patients With Persistent Atrial Fibrillation.

BACKGROUND

Catheter ablation outcomes remain suboptimal in patients with persistent atrial fibrillation (AF), and the optimal strategy beyond pulmonary vein isolation (PVI) has not been established. We evaluated whether a personalized strategy combining high-density voltage-guided segmental PVI and fractionation mapping-guided substrate modification improves clinical outcomes compared to anatomy-based circumferential PVI.

METHODS

This study prospectively enrolled 57 consecutive patients with persistent or long-standing persistent AF who underwent segmental PVI combined with fractionation mapping-guided ablation using the EnSite system (2019-2021). Clinical outcomes were compared with a retrospectively identified cohort of 57 patients who underwent anatomy-based circumferential PVI alone (2017-2021), matched for baseline characteristics. The primary endpoints were 1-year freedom from AF and AF/atrial tachycardia (AT) recurrence using Kaplan-Meier analysis and log-rank test. Multivariable Cox proportional hazard regression was performed to adjust for age and left atrial volume.

RESULTS

Kaplan-Meier analysis revealed that the intervention group had a significantly higher 1-year freedom from AF recurrence compared to the PVI only group (78.9% vs. 59.6%, log-rank p = 0.039). However, 1-year freedom from any AF/AT recurrence did not reach statistical significance between the two groups (71.9% vs. 56.1%, log-rank p = 0.137). After adjustment for age and left atrial volume, the intervention group showed a trend toward improved AF-free survival (adjusted hazard ratio [HR] 0.491, 95% CI 0.237-1.016, p = 0.055).

CONCLUSIONS

In patients with persistent AF, high-density fractionation mapping-guided ablation in addition to segmental PVI was associated with improved 1-year freedom from AF. This tailored substrate modification strategy may enhance rhythm control in this challenging population.