• Sandeep Prabhu, Manish Kalla, Kah Y Peck, Aleksandr Voskoboinik, McLellan Alex J A AJA Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia; Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; Cardi, Bupesh Pathik, Chrishan J Nalliah, Geoff R Wong, Hariharan Sugumar, Sonia M Azzopardi, Geoffrey Lee, Liang-Han Ling, Jonathan M Kalman, and Peter M Kistler.
• Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia; Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; Cardiology Department, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.
• Heart Rhythm. 2018 Jul 1; 15 (7): 980-986.

BackgroundPulmonary vein (PV) isolation (PVI) remains the cornerstone of catheter ablation (CA) in persistent atrial fibrillation (AF) (PeAF), although less successful than for paroxysmal AF. Whether rapid or fibrillatory (PV AF) PV firing may identify patients with PeAF more likely to benefit from a PV-based ablation approach is unclear.ObjectiveThe purpose of this study was to determine the relationship between the PV cycle length (PVCL) and the PV AF outcome after CA.MethodsBefore ablation, the multipolar catheter was placed in each PV and the left atrial appendage (LAA) for 100 consecutive cycles. The presence of PV AF, the average PVCL of all 4 veins (PV4VAverage), the fastest vein average (PVFVAverage), the fastest cycle length (PVFast) both individually and relative to the average LAA cycle length were calculated. The ablation strategy included PVI and posterior wall isolation with a minimum of 12 months follow-up.ResultsA total of 123 patients underwent CA (age 62 ± 9.1 years; CHA2DS2-VASC score 1.6 ± 1.1; left ventricular ejection fraction 48% ± 13%; left atrial area 31 ± 8.7 cm2; AF duration 16 ± 17 months). PVI was achieved in 100% of patients. Multiprocedure success (MPS; freedom from AF/atrial tachycardia episodes lasting >30 seconds) was achieved in 76% of patients at 24 ± 8.1 months of follow-up after 1.2 ± 0.4 procedures. PV activity was not associated with MPS either absolutely (PV4VAverage [MPS no vs yes: 178 ± 27 ms vs 177 ± 24 ms; P = .92], PVFVAverage [P = .69], or PVFast [P = .82]) or as a ratio relative to the LAA cycle length (PV4VAverage/LAA 1.05 ± 0.11 vs 1.06 ± 0.21; P = .87). The presence of PV AF (31% vs 47%; P = .13) did not predict MPS.ConclusionThe rapidity of PV firing or presence of fibrillation within the PV was not predictive of outcome of CA for PeAF. PV activity does not identify patients most likely to benefit from a PV-based ablation strategy.Copyright © 2018 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

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