Optimized Linear Ablation with EIVOM Enhances Rhythm Control in Persistent Atrial Fibrillation: PROMPT-AF Trial

Persistent AF poses a greater treatment challenge than paroxysmal AF due to its prolonged and more stable arrhythmic substrate. PVI has been the cornerstone of catheter ablation for AF, primarily targeting the pulmonary veins as the primary arrhythmia triggers. However, additional strategies may be necessary to improve long-term outcomes in persistent AF. Considering this, Caihua Sang, Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China, and colleagues aimed to assess whether adding linear ablation with radiofrequency energy and EIVOM to PVI enhances sinus rhythm maintenance compared to PVI alone in patients with persistent AF.

For this purpose, the researchers conducted the PROMPT-AF trial, a multicenter, open-label, randomized study across 12 tertiary hospitals in China. Four hundred ninety-eight patients aged 18 to 80 years with persistent AF for over three months undergoing first-time ablation were enrolled between 2021 and 2023. Patients were randomized to receive either PVI alone or PVI plus EIVOM and linear ablation. The intervention group first underwent EIVOM, followed by PVI and linear ablation targeting the left atrial roof, mitral isthmus, and cavotricuspid isthmus.

The primary endpoint was freedom from atrial arrhythmias lasting over 30 seconds without antiarrhythmic drugs at 12 months. Secondary outcomes included recurrence of AF and other atrial arrhythmias, AF burden, and quality-of-life improvements. Continuous monitoring was performed using wearable single-lead ECG patches, symptom-triggered ECGs, and Holter monitoring.

Study Findings

• Among 498 randomized patients, the primary analysis included 495 (99.4%), with a mean age of 61.1 years; 361 (72.9%) were male.
• After 12 months, 70.7% of patients who underwent PVI plus EIVOM and linear ablation remained free from atrial arrhythmias without antiarrhythmic drugs, compared to 61.5% in the PVI-alone group.
• The intervention group showed a significant reduction in arrhythmia recurrence (hazard ratio, 0.73).
• The effect remained consistent across all prespecified subgroups.
• Secondary outcome comparisons did not yield significant differences.

The findings revealed that among patients with persistent AF, adding linear ablation and EIVOM to PVI significantly improved freedom from atrial arrhythmias within 12 months compared to PVI alone. In the PROMPT-AF trial, a higher percentage of patients in the intervention group maintained sinus rhythm without antiarrhythmic drugs, with the effect remaining consistent across all prespecified subgroups.

"While secondary outcomes did not show significant differences, the findings highlight the additional benefit of linear ablation and EIVOM in enhancing rhythm outcomes for persistent AF ablation. These results suggest a more comprehensive ablation strategy may improve long-term success in managing persistent AF," the researchers concluded.

Reference:

Sang C, Liu Q, Lai Y, et al. Pulmonary Vein Isolation With Optimized Linear Ablation vs Pulmonary Vein Isolation Alone for Persistent AF: The PROMPT-AF Randomized Clinical Trial. JAMA. 2025;333(5):381–389. doi:10.1001/jama.2024.24438