Skip to main content
SpringerLink
Log in

Posterior wall isolation in persistent atrial fibrillation. Long-term outcomes of a repeat procedure strategy

  • Published:
Journal of Interventional Cardiac Electrophysiology Aims and scope Submit manuscript

Abstract

Background

Posterior wall isolation (PWI) added to pulmonary vein isolation (PVI) is increasingly used in ablation for persistent atrial fibrillation (PeAF) despite limited evidence of clinical benefit. We investigated the 5-year outcomes of a PVI + PWI ablation strategy with mandatory repeat procedures in PeAF.

Methods

Twenty-four patients with PeAF participated in this single-arm prospective study and underwent radiofrequency ablation (RFA) with wide area circumferential ablation (WACA), roof, and inferior lines for PVI + PWI which was reinforced if required during mandated repeat procedures after 6 months. Then, patients were followed for 60 months using continuous heart rhythm monitoring by implanted cardiac monitors (ICM) and atrial fibrillation effect on quality-of-life scoring (AFEQT; range: 20–100 points) for the initial 30 months.

Results

ICM-verified cumulated AF recurrence was 54% after 30 months but the ensuing AF burden was only median 0‰ [0 to 4.8‰] overall and 1‰ [0 to 8 ‰] among patients with any recurrence. AFEQT scores increased from baseline 60 points [48 to 72] to 93 points [84 to 96] at repeat procedures P < 0.0001 and further to 96 points [93 to 99] P = 0.03 after 30 months. After 60 months, at least one episode of AF had been documented in 63% and two patients (8%) were in permanent AF.

Conclusion

Reinforced PVI + PWI was associated with low long-term AF burden and corresponding improvements in quality-of-life. Reinforced (or durable) PVI + PWI appears to be a promising strategy to treat PeAF.

Trial registration

ClinicalTrials.gov. Identifier: NCT05045131

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

Data availability

All source data and calculations forming the basis of the conclusions in this work are available in anonymized form and will be provided by reasonable request to the corresponding author.

Abbreviations

PeAF:

Persistent atrial fibrillation

PVI :

Pulmonary vein isolation

PWI:

Left atrial posterior wall isolation

LA:

Left atrium

WACA:

Wide area circumferential ablation

ICM:

Implantable cardiac monitor

AI:

Ablation index

CRZ:

Center-right zone of the LA posterior wall

IQR :

Interquartile range

References

  1. Bai R, Di BL, Mohanty P, et al. Proven isolation of the pulmonary vein antrum with or without left atrial posterior wall isolation in patients with persistent atrial fibrillation. Heart Rhythm. 2016;13(1547–5271 (Linking)):132–140. https://doi.org/10.1016/j.hrthm.2015.08.019

  2. Barbhaiya CR, Knotts RJ, Beccarino N, et al. Multiple procedure outcomes for nonparoxysmal atrial fibrillation: left atrial posterior wall isolation versus stepwise ablation. J Cardiovasc Electrophysiol. 2020;31(12):3117–23. https://doi.org/10.1111/jce.14771.

    Article  PubMed  Google Scholar 

  3. Jiang X, Liao J, Ling Z, et al. Adjunctive left atrial posterior wall isolation in treating atrial fibrillation. JACC: Clinical Electrophysiol. 2022;8(5):605–18. https://doi.org/10.1016/j.jacep.2022.02.001.

    Article  Google Scholar 

  4. Worck R, Sørensen SK, Johannessen A, Ruwald M, Haugdal M, Hansen J. Posterior wall isolation in persistent atrial fibrillation feasibility, safety, durability, and efficacy. J Cardiovasc Electrophysiol. 2022;33(8):1667–74. https://doi.org/10.1111/jce.15556.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Verma A (2022) Strategies for catheter ablation of persistent atrial fibrillation: a randomized, comparative study. Clin Trials.gov; 2022. Accessed 4 Jul 2022. https://clinicaltrials.gov/ct2/show/NCT04428944

  6. Chieng D, Sugumar H, Ling LH, et al. Catheter ablation for persistent atrial fibrillation: a multicenter randomized trial of pulmonary vein isolation (PVI) versus PVI with posterior left atrial wall isolation (PWI) - The CAPLA study. Am Heart J. 2022;243:210–20. https://doi.org/10.1016/j.ahj.2021.09.015.

    Article  PubMed  Google Scholar 

  7. Spertus J, Dorian P, Bubien R, et al. Development and validation of the atrial fibrillation effect on QualiTy-of-Life (AFEQT) Questionnaire in patients with atrial fibrillation. Circ Arrhythm Electrophysiol. 2011;4(1):15–25. https://doi.org/10.1161/CIRCEP.110.958033.

    Article  PubMed  Google Scholar 

  8. Andrade JG, Deyell MW, Verma A, Macle L, Khairy P. The cryoballoon vs irrigated radiofrequency catheter ablation (CIRCA-DOSE) study results in context. Arrhythm Electrophysiol Rev. 2020;9(1):34–9. https://doi.org/10.15420/aer.2019.13.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Sørensen SK, Johannessen A, Worck R, Hansen ML, Hansen J. Radiofrequency versus cryoballoon catheter ablation for paroxysmal atrial fibrillation: durability of pulmonary vein isolation and effect on atrial fibrillation burden: the RACE-AF randomized controlled trial. Circ Arrhythm Electrophysiol. 2021;14(5):e009573. https://doi.org/10.1161/CIRCEP.120.009573.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Sulke N, Dulai R, Freemantle N, et al. Long term outcomes of percutaneous atrial fibrillation ablation in patients with continuous monitoring. Pacing Clin Electrophysiol. 2021;44(7):1176–84. https://doi.org/10.1111/pace.14282.

    Article  PubMed  Google Scholar 

  11. Valderrábano M, Peterson LE, Swarup V, et al. Effect of catheter ablation with vein of Marshall ethanol infusion vs catheter ablation alone on persistent atrial fibrillation: the VENUS randomized clinical trial. JAMA. 2020;324(16):1620–8. https://doi.org/10.1001/jama.2020.16195.

    Article  PubMed  Google Scholar 

  12. Reddy VY, Anic A, Koruth J, et al. Pulsed field ablation in patients with persistent atrial fibrillation. J Am Coll Cardiol. 2020;76(9):1068–80. https://doi.org/10.1016/j.jacc.2020.07.007.

    Article  PubMed  Google Scholar 

  13. Gupta D, Vijgen J, Potter TD, et al. Quality of life and healthcare utilisation improvements after atrial fibrillation ablation. Heart. 2021;107(16):1296–302. https://doi.org/10.1136/heartjnl-2020-318676.

    Article  PubMed  Google Scholar 

  14. Wechselberger S, Kronborg M, Huo Y, et al. Continuous monitoring after atrial fibrillation ablation: the LINQ AF study. Europace. 2018;20(FI_3):f312–20. https://doi.org/10.1093/europace/euy038.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Diederichsen SZ, Haugan KJ, Kronborg C, et al. Comprehensive evaluation of rhythm monitoring strategies in screening for atrial fibrillation: insights from patients at risk monitored long term with an implantable loop recorder. Circulation. 2020;141(19):1510–22. https://doi.org/10.1161/CIRCULATIONAHA.119.044407.

    Article  PubMed  Google Scholar 

  16. Balabanski T, Brugada J, Arbelo E, et al. Impact of monitoring on detection of arrhythmia recurrences in the ESC-EHRA EORP atrial fibrillation ablation long-term registry. EP Europace. 2019;21(12):1802–8. https://doi.org/10.1093/europace/euz216.

    Article  Google Scholar 

  17. Sanders P, Pürerfellner H, Pokushalov E, et al. Performance of a new atrial fibrillation detection algorithm in a miniaturized insertable cardiac monitor: results from the Reveal LINQ Usability Study. Heart Rhythm. 2016;13(7):1425–30. https://doi.org/10.1016/j.hrthm.2016.03.005.

    Article  PubMed  Google Scholar 

  18. Pothineni NVK, Amankwah N, Santangeli P, et al. Continuous rhythm monitoring-guided anticoagulation after atrial fibrillation ablation. J Cardiovasc Electrophysiol. 2021;32(2):345–53. https://doi.org/10.1111/jce.14864.

    Article  PubMed  Google Scholar 

  19. Sawhney N, Anousheh R, Chen W, Feld GK. Circumferential pulmonary vein ablation with additional linear ablation results in an increased incidence of left atrial flutter compared with segmental pulmonary vein isolation as an initial approach to ablation of paroxysmal atrial fibrillation. Circ Arrhythm Electrophysiol. 2010;3(3):243–8. https://doi.org/10.1161/CIRCEP.109.924878.

    Article  PubMed  Google Scholar 

  20. Calkins H, Hindricks G, Cappato R, et al. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Europace. 2018;20(1):e1–160. https://doi.org/10.1093/europace/eux274.

    Article  PubMed  Google Scholar 

  21. Pambrun T, Duchateau J, Delgove A, et al. Epicardial course of the septopulmonary bundle: Anatomical considerations and clinical implications for roof line completion. Heart Rhythm. 2021;18(3):349–57. https://doi.org/10.1016/j.hrthm.2020.11.008.

    Article  PubMed  Google Scholar 

  22. Takigawa M, Derval N, Frontera A, et al. Revisiting anatomic macroreentrant tachycardia after atrial fibrillation ablation using ultrahigh-resolution mapping: Implications for ablation. Heart Rhythm. 2018;15(3):326–33. https://doi.org/10.1016/j.hrthm.2017.10.029.

    Article  PubMed  Google Scholar 

  23. Pottegård A, Schmidt SAJ, Wallach-Kildemoes H, Sørensen HT, Hallas J, Schmidt M. Data resource profile: The Danish National Prescription Registry. Int J Epidemiol. 2017;46(3):798–798f. https://doi.org/10.1093/ije/dyw213.

    Article  PubMed  Google Scholar 

Download references

Funding

The study was mainly supported by the internal research fund of the department of cardiology, Gentofte Hospital. A grant from Biosense Webster Inc. covered a minor share of the required funding.

Author information

Authors and Affiliations

  1. Department of Cardiology, Copenhagen University Hospital Gentofte, Gentofte Hospitalsvej 1, DK-2900, Hellerup, Denmark

    René Worck, Samuel K. Sørensen, Arne Johannessen, Martin H. Ruwald, Morten Lock Hansen, Martin Haugdal & Jim Hansen

Authors
  1. René Worck
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Samuel K. Sørensen
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Arne Johannessen
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Martin H. Ruwald
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Morten Lock Hansen
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Martin Haugdal
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Jim Hansen
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

All authors contributed to the manuscript, approved the final version, and agreed to be co-authors.

Corresponding author

Correspondence to René Worck.

Ethics declarations

Ethics approval

The study was approved by the Danish National Science Ethics Committee (H15015153) and posted in a clinical trial database, www.clinicaltrials.gov (NCT05045131). All participants provided written informed consent.

Conflict of interests

Dr. Worck has received research grants and speaker honoraria from Biosense Webster. Dr. Sørensen has received research grants from Medtronic and Biosense Webster. Dr. Lock Hansen has received research grants from the Novo Nordisk Foundation and Dr. Hansen has received research grants and speaker honoraria from Medtronic, Biosense Webster, and Boston Scientific. Dr Johannesen, Dr. Ruwald, and Mr. Haugdal have nothing to disclose. There are no other potentially competing interests to declare.

Additional information

Publisher's note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 19 KB)

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Worck, R., Sørensen, S.K., Johannessen, A. et al. Posterior wall isolation in persistent atrial fibrillation. Long-term outcomes of a repeat procedure strategy. J Interv Card Electrophysiol 66, 971–979 (2023). https://doi.org/10.1007/s10840-022-01402-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10840-022-01402-x

Keywords

Search

Navigation