Background: The optimal way to map localized drivers in persistent atrial fibrillation (AF) remains unclear.
Objective: Compare procedural endpoints and freedom from AF/AT during long-term follow-up in patients undergoing pulmonary vein isolation (PVI) and further ablation guided by a novel mapping method called Stochastic Trajectory Analysis of Ranked signals (STAR) versus a PVI only approach in persistent AF patients.
Methods: Persistent AF patients in the STAR mapping study were included. The ablation strategy in these patients included radiofrequency (RF) PVI followed by STAR guided ablation of AF drivers (AFD) using simultaneously acquired data with basket catheters. Procedural endpoints (CL slowing ≥30ms and AF termination) and freedom from AF/AT during follow-up were compared to a control cohort comprised of all patients who underwent a RF PVI only procedure during the same recruitment period. A time-to-event analysis was performed on an intention to treat basis.
Results: Thirty-five patients were included in the STAR mapping study. Three patients terminated to sinus rhythm on PVI leaving 32 patients that underwent STAR guided ablation in addition to PVI. Thirty patients underwent planned PVI only approach during the same period. There was no significant difference in baseline characteristics between the groups. STAR guided ablation did not result in significantly greater ablation duration compared to a PVI only approach (40.2±19.5 vs. 45.2±16.7 minutes; p=0.36). A larger proportion of patients in the STAR guided ablation group achieved AF termination with ablation compared to the PVI only group (n=27, 77.1% vs. n=10, 33.3%; p<0.001). The rate of freedom from AF/AT was higher in the STAR guided ablation group compared to the PVI only group (80.0% vs. 50.0%; p=0.017) at 24.4±3.7 versus 22.6±5.8 months (p=0.14). Survival free from AF/AT was higher in the STAR guided ablation group versus the PVI only group (p=0.015).
Conclusion: STAR guided ablation in the addition of PVI results in significantly higher rates of AF termination and freedom from AF/AT during long-term follow-up compared to a PVI only ablation approach without the need for significantly greater amount of ablation. Prospective randomized trials are needed to confirm these early observations.