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Health See other Health Articles Title: Vein Isolation Should Be First Treatment for Ablation of Persistent AF Medscape... NEW YORK (Reuters Health) - Pulmonary vein isolation (PVI) should be favored over a stepwise approach aimed at termination of persistent atrial fibrillation (AF), according to findings from the CHASE-AF trial. PVI alone is a well-established therapy for paroxysmal AF, but it appears to be insufficient for treating persistent AF so other strategies have been developed, including ablation of complex fractionated atrial electrograms (CFAEs) in both atria and the coronary sinus (CS), isolation of the left atrial appendage (LAA), and development of linear lesions in the left atrium (LA). Dr. Julia Vogler, from University Hospital Eppendorf, Hamburg, Germany, and colleagues in the CHASE-AF trial compared PVI alone versus a full-defragmentation strategy consisting of PVI followed by biatrial ablation of CFAEs and linear ablation lines in 205 patients with persistent AF that did not terminate with a single PVI. During the study, 241 ablations were performed in 153 patients (mean, 1.59 per patient in the PVI-alone group and 1.55 per patient in the full-defrag group). After single and multiple procedures, arrhythmia-free survival (on drug therapy) did not differ between the PVI-alone group (39/61, 63.9%) and the full-defragmentation group (41/71, 57.7%)(p=0.468), according to the report in the December Journal of the American College of Cardiology. The drug-free overall one-year multiple procedure success rate was nearly the same with PVI-alone (51.4%) and full-defrag (50.0%). The stepwise approach was associated with a longer procedure duration, fluoroscopy time, and radiofrequency duration, but it did not result in a higher rate of major complications. "PVI should be the initial strategy in patients with persistent AF undergoing catheter ablation, because more extensive ablation is associated with longer procedure duration, fluoroscopy, and radiofrequency exposure without better rhythm control outcomes," the authors conclude. "Further studies are needed to define the safety and efficacy of ablation of AF rotors and other focal sources to improve outcomes in patients with persistent AF." Dr. Matthew Wright, from St. Thomas' Hospital, London, UK, wrote the editorial related to this report. He told Reuters Health by email, "The result is now not that surprising, but it certainly would have been a few years ago when the whole field of electrophysiology moved toward complex fractionated atrial electrogram (CFAE) ablation. This was incorporated into guidelines and was a standard part of how we performed AF ablations. Over the last year, with STAR AF II and now this data it is clear that 'routine' ablation of these types of signals is no longer supported by randomized controlled data." "The nuances in the data suggest that we need to better choose which patients come for an AF ablation, especially the persistent AF patients," Dr. Wright said. "The natural progression of AF from paroxysmal to persistent AF is known, but it is clear from this data and others that patients who have been in persistent AF for less than a year, and probably less than nine months do far better than those who have been in AF for longer. These data help physicians decide what sort of an ablation strategy to choose for an individual patient. While these data do not help in telling us the correct strategy for the ablation, they help in telling us what is the wrong strategy." "We are still searching for the ideal way to treat persistent AF patients," Dr. Wright concluded. "While we do relatively well we are not eliminating the condition with ablation. Randomized controlled trials are always important following the early pioneering work, as the pioneers may actually be onto something but widespread adoption is often more difficult. Nuances in patient selection, and selection of ablation targets often involves more than what is written in the manuscript." Dr. Vogler did not provide comments in time for this story. St. Jude Medical GmbH funded this research. One coauthor reported relevant relationships. SOURCE: http://bit.ly/1NrTfPO and http://bit.ly/1QPRRsP J Am Coll Cardiol 2015. Post Comment Private Reply Ignore Thread
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