Background: Although pulmonary vein isolation (PVI) remains the cornerstone of AF ablation, recent studies have suggested a benefit associated with PVI in conjunction with posterior wall isolation (PWI) in patients with persistent AF.
Objective: In this multicenter, prospective, randomized-controlled trial, we evaluated the acute and long-term outcomes of PVI+PWI versus PVI alone performed using the cryoballoon in a cohort of patients with symptomatic persistent/long-standing persistent AF. Furthermore, all patients received empiric cavotricuspid isthmus RF ablation.
Methods: We prospectively examined the procedural outcomes from 88 consecutive patients with symptomatic persistent/long-standing persistent AF who underwent PVI+PWI (n=44) versus PVI alone (n=44) using the cryoballoon.
Results: Baseline characteristics were similar between the groups (age: 67 ± 9 y; CHA₂DS₂-VASc: 2.5 ± 1.6; 65% male, left atrial volume: 125 ± 59 mL/m2). Overall, 62% of the cohort presented with persistent AF (PVI+PWI: 59% Vs PVI only: 66%; P=0.51) and 38% with long-standing persistent AF. Acute isolation was achieved in 341/345 PVs (98.8%; PVI+PWI: 98.3% Vs PVI only: 99.4%; P=0.37), using 21 ± 11 min of cryoablation (PVI+PWI: 20 ± 11 min Vs PVI only: 23 ± 12 min; P=0.22). PWI was achieved in 41/44 patients (93.2%) using 24 ± 7 min of cryoablation. Adjunct radiofrequency ablation was required in 16 patients (36.4%) to complete PWI (8 ± 7 min). As expected, PVI+PWI was associated with a longer left atrial dwell (110 ± 31 min Vs 74 ± 32 min; P<0.001) and procedure time (170 ± 34 min Vs 132 ± 39 min; P<0.001), with similar fluoroscopy time (29 ± 18 min Vs 28 ± 16 min; P=0.65). There was no difference in the rate of AF termination (9.1% Vs 4.5%; P=0.42), adverse events (2.3% Vs 4.5%; P=0.74) or antiarrhythmic therapy beyond 3 months (22.7% Vs 29.5%; P=0.35) with PVI+PWI versus PVI, nor were there any deaths or atrioesophageal fistulas. However, there was a trend toward lower AF recurrence with PVI+PWI versus PVI alone at 1 year (25% Vs 45.5%; P=0.06).
Conclusion: PVI+PWI can be performed safely using the cryoballoon in patients with symptomatic persistent AF. Though underpowered to detect a significant difference, this study found a trend toward lower AF recurrence associated with PVI+PWI versus PVI alone.