Pulmonary vein isolation with myocardium ablation improves AF outcomes: NEJM

Results in patients with persistent atrial fibrillation (AF) were dramatically improved by pulmonary vein isolation (PVI) combined with customized ablation of atrial low-voltage myocardium, says an article published in The New England Journal of Medicine.

There is ongoing discussion over clinically viable ablation techniques for patients with persistent atrial fibrillation. In randomized controlled clinical trials, ablation targets and methods other than pulmonary vein isolation have not yet demonstrated a consistent improvement in outcome. In order to enhance rhythm regulation in patients with persistent AF, Yan Huo and team report a controlled trial comparing ablation of atrial low-voltage myocardium combined with PVI to PVI alone.

To find out whether PVI combined with customized substrate ablation of atrial low-voltage myocardium improves outcomes in patients with persistent AF, researchers undertook a multicenter, randomized experiment. They distributed PVI alone to 163 patients (163 patients; PVI only) or PVI with substrate modification to 161 patients (161 patients; PVI+SM) at random among 324 individuals. Using serial 7-day ECG recordings during 12 months of surveillance, the primary study end goal was the first occurrence of an atrial arrhythmia lasting more than 30 seconds following a single ablation, with 3 months blanking. Implantable heart monitors were also advised for patients.

The key findings of this study were:

1. In 75 PVI-only patients (50%) and 54 PVI+SM patients (35%), the primary study end goal was reached.

2. Three PVI-only patients (1.8%) and six PVI+SM patients (3.7%) experienced negative outcomes. In 242 individuals, implant monitoring was employed.

3. Recurrences occurred in 65 PVI-only patients (55%) versus 47 PVI+SM patients (39%) among them.

In conclusion, In the ERASE-AF trial, it was discovered that PVI+SM was more effective than pulmonary vein isolation (PVI) alone at treating patients with persistent atrial fibrillation and preventing recurrent atrial arrhythmias.

Reference: 

Huo, Y., Gaspar, T., Schönbauer, R., Wójcik, M., Fiedler, L., Roithinger, F. X., Martinek, M., Pürerfellner, H., Kirstein, B., Richter, U., Ulbrich, S., Mayer, J., Zedda, A., Piorkowski, J., & Piorkowski, C. (2022). Low-Voltage Myocardium-Guided Ablation Trial of Persistent Atrial Fibrillation. In NEJM Evidence (Vol. 1, Issue 11). Massachusetts Medical Society. https://doi.org/10.1056/evidoa2200141