• Thomas Fink, Michael Schlüter, Christian-Hendrik Heeger, Christine Lemes, Tilman Maurer, Bruno Reissmann, Johannes Riedl, Laura Rottner, Francesco Santoro, Boris Schmidt, Peter Wohlmuth, Shibu Mathew, Christian Sohns, Feifan Ouyang, Andreas Metzner, and Karl-Heinz Kuck.
• From the Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany (T.F., C.-H.H., C.L., T.M., B.R., J.R., L.R., F.S., B.S., S.M., C.S., F.O., A.M., K.-H.K.); and Asklepios Proresearch, Hamburg, Germany (M.S., P.W.).
• Circ Arrhythm Electrophysiol. 2017 Jul 1; 10 (7).

BackgroundPulmonary vein isolation (PVI) for persistent atrial fibrillation is associated with limited success rates and often requires multiple procedures to maintain stable sinus rhythm. In the prospective and randomized Alster-Lost-AF trial (Ablation at St. Georg Hospital for Long-Standing Persistent Atrial Fibrillation), we sought to assess, in patients with symptomatic persistent or long-standing persistent atrial fibrillation, the outcomes of initial ablative strategies comprising either stand-alone PVI (PVI-only approach) or a stepwise approach of PVI followed by complex fractionated atrial electrogram ablation and linear ablation (Substrate-modification approach).Methods And ResultsPatients were randomized 1:1 to stand-alone PVI or PVI plus substrate modification. The primary study end point was freedom from recurrence of any atrial tachyarrhythmia, outside a 90-day blanking period, at 12 months. A total of 124 patients were enrolled, with 118 patients included in the analysis (61 in the PVI-only group, 57 in the Substrate-modification group). Atrial tachyarrhythmias recurred in 28 PVI-only group patients and 24 Substrate-modification group patients, for 1-year freedom from tachyarrhythmia recurrence after a single ablation procedure of 54% (95% confidence interval, 43%-68%) in the PVI-only and 57% (95% confidence interval, 46%-72%) in the Substrate-modification group (P=0.86). Twenty-four patients in the PVI-only group (39%) and 18 in the Substrate-modification group (32%) were without arrhythmia recurrence and off antiarrhythmic drug therapy at the end of the 12-month follow-up.ConclusionsIn patients with persistent and long-standing persistent atrial fibrillation, no significant difference was observed in 12-month freedom from atrial tachyarrhythmias between an index ablative approach of stand-alone PVI and a stepwise approach of PVI plus complex fractionated atrial electrogram and linear ablation.Clinical Trial RegistrationURL: http://www.clinicaltrials.gov. Unique identifier: NCT00820625.© 2017 American Heart Association, Inc.

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