Stepwise ablation controls some persistent afib up to 5 years

Long-term results from a French study on persistent atrial fibrillation suggest that a stepwise catheter ablation strategy may terminate atrial fibrillation in some patients for as long as five years after a procedure.

The study, published in the February issue of Circulation: Arrhythmia and Electrophysiology, noted that the procedure may need to be repeated, but freedom from arrhythmia can be achieved in the majority of patients. Daniel Scherr, MD, of the Hôpital Cardiologique du Haut Lévêque in Pessac, France, and the Medical University of Graz in Austria, and colleagues enrolled 150 patients with persistent atrial fibrillation between 2003 and 2007.

Patients underwent a stepwise ablation that included pulmonary vein isolation, electrogram-based ablation and linear ablation, in that order, in an attempt to achieve sinus rhythm. Most patients required at least two procedures (44 percent), however, 27.3 percent had one procedure and 20.7 percent had three. A small number (1.4 percent) required five or six procedures. Ablation terminated atrial fibrillation in 80 percent. While no procedure-related deaths were reported, 4.4 percent of procedures had complications.

Overall arrhythmia-free survival following the last procedure was 89.7 percent at one year, 79.8 percent at two years and 62.9 percent at five years. Use of antiarrhythmic drugs had some effect on long-term success of arrhythmia-free survival.

For patients with a single procedure, arrhythmia-free survival was 35.3 percent, 28 percent and 16.8 percent at one, two and five years, respectively.

Successful termination of arrhythmia was characterized by a shorter duration of continuous atrial fibrillation and smaller left atrium diameter. The strongest predictor of arrhythmia recurrence was failure to terminate atrial fibrillation during an index procedure (hazard ratio 3.831). Other predictors of recurrence included left atrial diameter of 50 mm or greater, continuous atrial fibrillation duration of 18 months or more and structural heart disease.

While ablation is an established treatment for paroxysmal atrial fibrillation, Scherr et al wrote, limited long-term data has so far confounded predictors for successful ablation for persistent atrial fibrillation.  “In PsAF [persistent atrial fibrillation] patients, a stepwise catheter ablation strategy with AF [atrial fibrillation] termination as a procedural end point and with repeat interventions as needed provides acceptable freedom from arrhythmia recurrence over a 5-year follow-up period,” they wrote.