Pulmonary Vein Isolation With or Without Posterior Wall Isolation

In a randomized controlled trial, published in JAMA, researchers compared pulmonary vein isolation (PVI) with posterior wall isolation (PWI) versus PVI alone in patients with persistent atrial fibrillation undergoing first-time catheter ablation. Based on their findings, they concluded the combination of PVI and PWI did not significantly improve atrial arrhythmia recurrence after 1 year compared with PVI alone in their study’s population.

The multicenter randomized controlled trial was conducted from July 2018 to March 2021 in 11 centers across Australia, Canada, and the UK. In the trial, 168 patients underwent wide antral PVI alone and 170 underwent wide antral PVI followed by PWI comprised of linear ablation at the roof and floor. Participants were followed for 1 year, ending in March 2022.

PVI With or Without PWI in Atrial Fibrillation

The primary end point after was freedom from documented atrial arrhythmia lasting more than 30 seconds at 12 months with 1 ablation procedure and without the use of antiarrhythmic medication. Additional end points included freedom from atrial arrhythmias and symptomatic atrial fibrillation after multiple ablation procedure, with or without antiarrhythmic medication, as well as atrial fibrillation burden, procedural outcomes, and complications.

The initial cohort included 338 patients with persistent atrial fibrillation, of which 330 (97.6%) completed the 12 month follow-up. At that point, 90 (52.4%) patients in the PVI with PWI group and 90 (53.6%) in the PVI alone group were free from arrhythmia recurrence without medication after 1 procedure (between group difference, -1.2%; hazard ratio [HR], 0.99; 95% CI, 0.73-1.36; P=.98).

Likewise, freedom from arrhythmia with or without medication after multiple procedures was  58.2% for PVI with PWI and 60.1% for PVI (HR, 1.10; 95% CI, 0.79-1.55; P=.57). In addition, 8 other secondary end points were comparable between the groups, including freedom from symptomatic atrial fibrillation with or without medication and multiple procedures and atrial fibrillation burden. Both mean procedure time and ablation time were significantly shorter in the PVI group.

In summary, the authors wrote “in patients undergoing first-time catheter ablation for persistent AF, the addition of PWI to PVI alone did not significantly improve freedom from atrial arrhythmia at 12 months compared with PVI alone.”

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