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Wide area circumferential pulmonary vein isolation (PVI), also referred to as antral PVI, is the most frequently utilized strategy in patients undergoing atrial fibrillation (AF) ablation.1 Although widely practiced, the single procedure success rate of this approach has consistently been better in patients with paroxysmal as than in those with persistent AF.1–3 This discrepancy has been attributed to the difference in the mechanism(s) underlying the 2 types of AF.4 It has been posited that early on in the course of AF, triggers predominate. As the arrhythmia becomes more established, there are changes in the underlying substrate, which promote AF persistence, that is, AF begets AF.4,5 Although this hypothesis remains to be proven, it has nevertheless resulted in the development of adjunctive substrate modification strategies for enhancing procedural efficacy in patients with more persistent forms of AF. These include empirical linear lesions across potential reentrant channels, targeting complex fractionated electrograms (CFEs), ablating ganglionated plexi or AF nests, etc.4,6,7 Initial experience from operators/centers who developed some of these techniques showed their benefit in improving long-term ablation outcomes beyond PVI in patients with persistent AF.4,6,7 However, these initial favorable results have not been consistently reproduced, particularly when tested in prospective randomized comparisons. Our group was one of the first to conduct a prospective randomized study (RASTA trial [Randomized Ablation Strategies for the Treatment of Persistent Atrial Fibrillation]) to assess the efficacy of CFE ablation for enhancing single procedure efficacy beyond PVI in an exclusive group of patients with persistent and long-standing persistent AF. We found that freedom from atrial arrhythmias at 1 year after a single ablation procedure off antiarrhythmic drug (AAD) therapy was significantly worse in patients randomized to additional CFE ablation beyond PVI …

circulation. arrhythmia and electrophysiology

Modifying Arrhythmia Behavior Preablation With Drug Therapy May Improve Single Procedure Efficacy of a Limited Ablation Strategy in Patients With Persistent Atrial Fibrillation