• Gareth J Wynn, Sandeep Panikker, Maureen Morgan, Mark Hall, Johan Waktare, Vias Markides, Wajid Hussain, Tushar Salukhe, Simon Modi, Julian Jarman, David G Jones, Richard Snowdon, Derick Todd, Tom Wong, and Dhiraj Gupta.
• Institute of Cardiovascular Medicine and Science, Liverpool & London, United Kingdom; Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; Imperial College London, London, United Kingdom.
• Heart Rhythm. 2016 Feb 1; 13 (2): 399-406.

BackgroundMore advanced atrial fibrillation (AF) is associated with lower success rates after pulmonary vein isolation (PVI), and the optimal ablation strategy is uncertain.ObjectivesTo assess the impact of additional linear ablation (lines) compared to PVI alone.MethodsIn this multicenter randomized controlled trial, 122 patients (mean age 61.9 ± 10.5 years; left atrial diameter 43 ± 6 mm) with persistent AF (PeAF) or sustained (>12 hours) paroxysmal AF (SusPAF) with risk factors for atrial substrate were included and followed up for 12 months. Patients were randomized to PVI-only or PVI + lines (left atrial roof line, mitral isthmus line, and tricuspid isthmus line) group. Holter monitoring was performed at 3, 6, and 12 months and according to symptoms. The primary outcome was atrial tachyarrhythmia recurrence lasting ≥30 seconds.ResultsBaseline characteristics were comparable between groups; 61% had PeAF and 39% SusPAF. Successful PVI was achieved for 98% of pulmonary veins, and bidirectional block was obtained in 90% of lines. The primary end point occurred in 38% of the PVI + lines group and 32% of the PVI-only group (P = .50), which was consistent in both PeAF (36% vs 28%; P = .45) and SusPAF (42% vs 39%; P = .86). Compared with the PVI-only group, the PVI + lines group had higher procedure duration (209 ± 52 minutes vs 172 ± 44 minutes; P < .001), ablation time (4352 ± 1084 seconds vs 2503 ± 1061 seconds; P < .001), and radiation exposure (Dose-area product 3992 ± 6496 Gy·cm(2) vs 2106 ± 1679 Gy·cm(2); P = .03). Quality of life (disease-specific Atrial Fibrillation Effect on Quality of Life questionnaire and mental component scale of the Short Form 36 Health Survey) improved significantly during the study but did not differ between groups.ConclusionAdding lines to wide antral PVI in substrate-based AF requires significantly more ablation, increases procedure duration and radiation dose, but provides no additional clinical benefit.Copyright © 2016 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

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