Improved outcome following restoration of sinus rhythm prior to catheter ablation of persistent atrial fibrillation: A comparative multicenter study

BACKGROUND Catheter ablation of persistent atrial fibrillation (AF) is associated with longer procedure times and lower long-term success rates than that of paroxysmal AF. OBJECTIVE To test the hypothesis that restoration/maintenance of sinus rhythm (SR) preablation would facilitate AF termination and improve outcomes in patients with persistent AF. METHODS We conducted a 2-group cohort study of consecutive patients with persistent AF and SR restored for at least 1 month prior to ablation (SR group; n = 40) and controls matched by age, sex, and AF duration (control group; n = 40). Radiofrequency stepwise catheter ablation was performed in AF for both groups (induced and spontaneous, respectively). Success was defined as freedom from atrial tachyarrhythmia without antiarrhythmic drugs beyond 1 year of follow-up. RESULTS During the index ablation procedure, AF cycle length was longer in the SR group than in the control group (183 +/- 32 ms vs 166 +/- 20 ms; P = .06), suggestive of reverse remodeling. In the SR group, AF more frequently terminated during ablation (95.0% vs 77.5%; P < .05) and required less extensive ablation of complex fractionated electrograms (40.0% vs 87.5%; P < .001) and linear lesions (42.5% vs 82.5%; P < .001). Mean procedural (199.8 +/- 69.8 minutes vs 283.5 +/- 72.3 minutes; P < .001), fluoroscopy (51.0 +/- 24.9 minutes vs 96.3 +/- 32.1 minutes; P < .001), and radiofrequency energy delivery (47.5 +/- 18.9 minutes vs 97.0 +/- 30.6 minutes; P < .001) times were shorter in the SR group. Clinical success rates were similar between groups for first (55.0% vs 45.0%; P = .28) and last (80.0% vs 70.0%; P = .28) procedures, during similar follow-up periods (21.1 +/- 9.7 months). CONCLUSIONS Restoration of SR prior to catheter ablation for persistent AF whenever possible decreases the extent of ablation with the same high clinical efficacy.