title: Long-Term Clinical Results of 2 Different Ablation Strategies in Patients With Paroxysmal and Persistent Atrial Fibrillation Efficacy of adjuvant anterior left atrial ablation during intracardiac echocardiography-guided pulmonary vein antrum isolation for atrial fibrillation. Substrate modification combined with pulmonary vein isolation improves outcome of catheter ablation in patients with persistent atrial fibrillation: a prospective randomized comparison. Randomized Evaluation of Right Atrial Ablation After Left Atrial Ablation of Complex Fractionated Atrial Electrograms for Long-Lasting Persistent Atrial Fibrillation Small or Large Isolation Areas Around the Pulmonary Veins for the Treatment of Atrial Fibrillation?: Results From a Prospective Randomized Study Role of pulmonary veins isolation in persistent atrial fibrillation ablation: the pulmonary vein isolation in persistent atrial fibrillation (PIPA) study. Impact of systematic isolation of superior vena cava in addition to pulmonary vein antrum isolation on the outcome of paroxysmal, persistent, and permanent atrial fibrillation ablation: results from a randomized study. Randomized comparison of encircling and nonencircling left atrial ablation for chronic atrial fibrillation. Ablation for longstanding permanent atrial fibrillation: results from a randomized study comparing three different strategies. Image integration-guided catheter ablation of atrial fibrillation: a prospective randomized study. Steerable Versus Nonsteerable Sheath Technology in Atrial Fibrillation Ablation: A Prospective, Randomized Study Radiofrequency ablation for persistent atrial fibrillation in patients with advanced heart failure and severe left ventricular systolic dysfunction: a randomised controlled trial Complex fractionated atrial electrogram or linear ablation in patients with persistent atrial fibrillation--a prospective randomized study. Catheter ablation vs. antiarrhythmic drug treatment of persistent atrial fibrillation: a multicentre, randomized, controlled trial (SARA study) Left Atrial Appendage: An Underrecognized Trigger Site of Atrial Fibrillation Circumferential pulmonary-vein ablation for chronic atrial fibrillation. Substrate and Trigger Ablation for Reduction of Atrial Fibrillation (STAR AF): a randomized, multicentre, international trial† Treatment of atrial fibrillation by the ablation of localized sources: CONFIRM (Conventional Ablation for Atrial Fibrillation With or Without Focal Impulse and Rotor Modulation) trial. A randomized assessment of the incremental role of ablation of complex fractionated atrial electrograms after antral pulmonary vein isolation for long-lasting persistent atrial fibrillation. Left mitral isthmus ablation associated with PV Isolation: long-term results of a prospective randomized study. Segmental pulmonary vein antrum isolation using the "large-size" lasso catheter in patients with atrial fibrillation. Catheter ablation treatment in patients with drug-refractory atrial fibrillation: a prospective, multi-centre, randomized, controlled study (Catheter Ablation For The Cure Of Atrial Fibrillation Study). Randomized Ablation Strategies for the Treatment of Persistent Atrial Fibrillation: RASTA Study Extensive antiarrhythmic drugs after catheter ablation of persistent atrial fi brillation High-frequency stimulation of the atria increases early recurrence following pulmonary vein isolation in patients with persistent atrial fibrillation. Circumferential pulmonary vein ablation: does use of a circular mapping catheter improve results? A prospective randomized study. A randomized trial to compare atrial fibrillation ablation using a steerable vs. a non-steerable sheath. Left Atrial Posterior Wall Isolation Does Not Improve the Outcome of Circumferential Pulmonary Vein Ablation for Atrial Fibrillation: A Prospective Randomized Study Left atrial ablation versus biatrial ablation for persistent and permanent atrial fibrillation: a prospective and randomized study. Completion of mitral isthmus ablation using a steerable sheath: prospective randomized comparison with a nonsteerable sheath. The impact of CT image integration into an electroanatomic mapping system on clinical outcomes of catheter ablation of atrial fibrillation. Efficacy of additional ablation of complex fractionated atrial electrograms for catheter ablation of nonparoxysmal atrial fibrillation. Additional left atrial septal line does not improve outcome of patients undergoing ablation for long-standing persistent atrial fibrillation Comparison of voltage map-guided left atrial anterior wall ablation versus left lateral mitral isthmus ablation in patients with persistent atrial fibrillation. Single-Ring Posterior Left Atrial (Box) Isolation Results in a Different Mode of Recurrence Compared With Wide Antral Pulmonary Vein Isolation on Long-Term Follow-Up: Longer Atrial Fibrillation–Free Survival Time but Similar Survival Time Free of Any Atrial Arrhythmia A randomized trial to assess catheter ablation versus rate control in the management of persistent atrial fibrillation in heart failure. Cooled-tip vs. 8 mm-tip catheter for circumferential pulmonary vein ablation: comparison of efficacy, safety, and lesion extension. Usefulness of ablation of complex fractionated atrial electrograms using nifekalant in persistent atrial fibrillation. Comparison of the point-by-point versus catheter dragging technique for curative radiofrequency ablation of atrial fibrillation. Phased RF ablation in persistent atrial fibrillation. Recurrence of pulmonary vein conduction and atrial fibrillation after pulmonary vein isolation for atrial fibrillation: a randomized trial of the ostial versus the extraostial ablation strategy. Efficacy and safety of segmental ostial versus circumferential extra-ostial pulmonary vein isolation for atrial fibrillation. Electrogram-guided substrate ablation with or without pulmonary vein isolation in patients with persistent atrial fibrillation.
abstract: Background — Data regarding the long-term efficacy of atrial fibrillation ( AF ) ablation are still lacking . Methods and Results —Two hundred four consecutive patients symptomatic for paroxysmal or persistent/permanent AF were r and omly assigned to 2 different ablation schemes : pulmonary vein isolation ( PVI ) and PVI plus left linear lesions ( LL ) . Primary end point was to assess the maintenance of sinus rhythm ( SR ) after procedures 1 and 2 in the absence of antiarrhythmic drugs in a long-term follow-up of at least 3 years . Paroxysmal AF — With a single procedure at 12-month follow-up , 46 % of patients treated with PVI maintained SR , whereas at 3-year follow-up , 29 % were in SR ; using the “ PVI plus LL ” at the 12-month follow-up , 57 % of patients were in SR , whereas at the 3-year follow-up , 53 % remained in SR . After a second procedure , the long-term overall success rate without antiarrhythmic drugs was 62 % with PVI and 85 % with PVI plus LL . Persistent/Permanent AF — With a single procedure at the 12-month follow-up , 27 % of patients treated with PVI were in SR , whereas at the 3-year follow-up , 19 % maintained SR ; using the PVI plus LL with a single procedure at the 12-month follow-up 45 % of patients were in SR , whereas at the 3-year follow-up , 41 % remained in SR . After a second procedure , the long-term overall success rate without antiarrhythmic drugs was 39 % with PVI and 75 % with PVI plus LL . Conclusions —A long-term follow-up of AF ablation shows that short-term results can not be considered permanent because AF recurrences are still present after the first year especially in patients who have had “ PVI ” strategy .  PVI isolation plus LL is superior to the PVI strategy in maintaining SR without antiarrhythmic drugs after procedures 1 and 2 both in paroxysmal and persistent AF BACKGROUND Recent data have shown that the septum and anterior left atrial ( LA ) wall may contain " rotor " sites required for AF maintenance . However , whether adding ablation of such sites to st and ard ICE-guided PVAI improves outcome is not well known . OBJECTIVE To determine if adjuvant anterior LA ablation during PVAI improves the cure rate of paroxysmal and permanent AF . METHODS One hundred AF patients ( 60 paroxysmal , 40 persistent/permanent ) undergoing first-time PVAI were enrolled over three months to receive adjuvant anterior LA ablation ( Group I ) . These patients were compared with 100 r and omly selected , matched first-time PVAI controls from the preceding three months who did not receive adjuvant ablation ( Group II ) . All 200 patients underwent ICE-guided PVAI during which all four PV antra and SVC were isolated . In group I , a decapolar lasso catheter was used to map the septum and anterior LA wall during AF ( induced or spontaneous ) for continuous high-frequency , fractionated electrograms ( CFAE ) . Sites where CFAE were identified were ablated until the local EGM was eliminated . A complete anterior line of block was not a requisite endpoint . Patients were followed up for 12 months . Recurrence was assessed post-PVAI by symptoms , clinic visits , and Holter at 3 , 6 , and 12 months . Patients also wore rhythm transmitters for the first 3 months . Recurrence was any AF/AFL > 1 min occurring > 2 months post-PVAI . RESULTS Patients ( age 56 + /- 11 years , 37 % female , EF 53%+/- 11 % ) did not differ in baseline characteristics between group I and II by design . Group I patients had longer procedure time ( 188 + /- 45 min vs 162 + /- 37 min ) and RF duration ( 57 + /- 12 min vs 44 + /- 20 min ) than group II ( P < 0.05 for both ) . Overall recurrence occurred in 15/100 ( 15 % ) in group I and 20/100 ( 20 % ) in group II ( P = 0.054 ) . Success rates did not differ for paroxysmal patients between group I and II ( 87 % vs 85 % , respectively ) . However , for persistent/permanent patients , group I had a higher success rate compared with group II ( 82 % vs 72 % , P = 0.047 ) . CONCLUSIONS Adjuvant anterior LA ablation does not appear to impact procedural outcome in patients with paroxysmal AF but may offer benefit to patients with persistent/permanent AF AIMS To investigate the effectiveness of additional substrate modification ( SM ) by left atrial ( LA ) linear lesions as compared with pulmonary vein isolation ( PVI ) alone in patients with persistent atrial fibrillation ( AF ) in a prospect i ve r and omized study . Percutaneous PVI has evolved as an accepted treatment for paroxysmal AF but seemed to be less effective in patients with persistent AF . The benefit of PVI alone and additional linear lesions has not been vali date d in a r and omized study so far . METHODS AND RESULTS Sixty-two patients with persistent AF ( median duration 7 , range 1 - 18 months ) were r and omly assigned to either PVI alone ( n = 30 ) or additional SM ( n = 32 ) consisting of a roof line connecting both left superior and right superior PV and LA isthmus ablation between left inferior PV and mitral annulus . Procedures including SM were performed using a three-dimensional mapping system ( EnSite NavX , St Jude Medical , St Paul , MN , USA ) . Anti-arrhythmic drugs were discontinued within 8 weeks after ablation in both groups . Follow-up included daily trans-telephonic ECG transmitted irrespective of the patient 's symptoms . PVI was successful in 98 % of all targeted veins in both groups . Additional SM did not increase fluoroscopy time ( 72.1+/-18.7 vs. 72.9+/-17.3 min , P=0.92 ) because of the use of three-dimensional navigation in the PVI+SM group . AF recurrences within the first 4 weeks following ablation were more common after PVI alone ( 77 % ) than additional SM ( 44 % , P=0.002 ) . After a follow-up time of 487 ( 429 - 570 ) days , only 20 % of patients undergoing st and alone PVI  remained in sinus rhythm when compared with 69 % following PVI combined with SM ( P=0.0001 ) . Two patients assigned to PVI+SM experienced procedure-related complications ( cardiac tamponade and minor stroke ) which resolved without sequelae . CONCLUSION PVI alone is insufficient in the treatment of persistent AF . However , additional left linear lesions increase the success rate significantly . Early AF-relapses are associated with a negative outcome after PVI alone but not following additional SM Background —With electrogram-guided radiofrequency ablation ( RFA ) of long-lasting persistent atrial fibrillation ( AF ) , the best results have been reported when complex fractionated electrograms ( CFAEs ) in both the left ( LA ) and right ( RA ) atria were targeted . However , many studies have reported excellent outcomes from RFA of long-lasting persistent AF with the use of other ablation strategies that were limited to the LA . The incremental value of RFA of RA CFAEs is yet to be defined . Methods and Results —In 85 patients with long-lasting persistent AF ( age=59±10 years ) , RFA was directed at CFAEs in the LA and coronary sinus until AF terminated ( 19 ) or all identified LA CFAEs were eliminated . Sixty-six patients who remained in AF were r and omly assigned to cardioversion and no further RFA ( n=33 ) or to RFA of RA CFAEs ( n=33 ) . RA sites consisted of the crista terminalis ( 69 % ) , septum ( 38 % ) , superior vena cava ( 28 % ) , coronary sinus ostium ( 22 % ) , and the base of the appendage ( 31 % ) . AF terminated in 1 ( 3 % ) of 33 patients during RA RFA . At 17±6 months after a single ablation procedure , 74 % of the patients in whom AF terminated during LA RFA were in sinus rhythm . Rates of freedom from AF were similar in the patients r and omized to no RFA in the RA ( 24 % ) and those r and omized to RFA of RA CFAEs ( 30 % , P=0.8 ) . The ablation procedure was repeated in 26 patients ( 31 % ) for AF ( n=22 ) or atrial flutter ( n=4 ) . At 16±7 months after the final procedure , 89 % of the patients in whom AF terminated during LA RFA were in sinus rhythm . Among the r and omized patients , the proportion of patients who remained in sinus rhythm was similar in patients who did not undergo RFA of RA CFAEs ( 52 % ) and those who did ( 58 % , P=0.6 ) . Conclusion —After RFA of CFAEs in the LA and coronary sinus , ablation of CFAEs in the RA provides little or no increment in efficacy among patients with long-lasting persistent AF Background — Pulmonary vein ( PV ) isolation is a promising new treatment for  atrial fibrillation ( AF ) . We hypothesized that isolation of large areas around both ipsilateral PVs with verification of conduction block is more effective than the isolation of each individual PV . Methods and Results — A total of 110 patients , 67 with paroxysmal AF and 43 with persistent AF , were r and omly assigned to undergo either isolation of each individual PV or isolation of large areas around both ipsilateral PVs . The isolation of each individual PV was an electrophysiologically guided , ostial segmental ablation with a 64-pole basket catheter or a 20-pole circular mapping catheter ( group I ) . Isolation of large areas was performed around the 2 ipsilateral veins with a nonfluoroscopic navigation system and a circular 20-pole mapping catheter for verification of conduction block ( group II ) . In both groups , an irrigated-tip ablation catheter ( 25 to 35 W ) was used to achieve complete isolation . Procedure and ablation times were longer in group II , whereas fluoroscopic time was significantly shorter ( P≤0.001 ) . After a follow-up period of 15±4 months , 27 patients in group I ( 49 % ) and 37 patients in group II ( 67 % ) remained free of symptoms of AF and had no AF or atrial flutter during repetitive Holter monitoring without antiarrhythmic drug treatment after a single procedure ( P≤0.05 ) . Conclusions — The rate of success was significantly higher and fluoroscopy times were significantly lower in the group with large isolation areas around both ipsilateral PVs than in those who underwent individual PV isolation BACKGROUND The role of pulmonary veins ( PV ) isolation in patients with persistent atrial fibrillation ( AF ) is still debated . The aim of this study was to evaluate the adjunctive role of PV isolation in patients with persistent AF who underwent circumferential PV ablation ( anatomical approach ) . METHODS We treated 97 consecutive patients presenting with drug-refractory persistent AF by an anatomical approach ( group A , n = 36 , mean age = 60 + /- 8 years , 29 males ) or an integrated approach ( group B , n = 61 , mean age 59 + /- 10 years , 48 males ) . In all patients , radiofrequency ( RF ) ablation was performed by means of a nonfluoroscopic navigation system , in order to anatomically create circumferential lines around the PV . In group B , the persistence of PV potentials was ascertained with a multipolar circular catheter . If PV potentials persisted , RF energy targeting the electrophysiological breakthroughs was delivered to disconnect the PV . Past a 2-month period of observation , success was defined as absence of any atrial tachyarrhythmia recurrence lasting > 30 seconds . RESULTS Total procedure duration ( 220 + /- 62 minutes vs 140 + /- 43 minutes , P < 0.001 ) , fluoroscopy time ( 35 + /- 15 minutes vs 17 + /- 9 minutes , P < 0.001 ) , and RF delivery time ( 48 + /- 22 minutes vs 27 + /- 9 minutes , P < 0.001 ) were significantly longer in group B than in group A. One cardiac perforation occurred in group A. After 15 + /- 9.1 months , 21 patients in group A ( 58 % ) and 34 patients in group B ( 56 % ) were free of atrial tachyarrhythmia recurrence ( P = 0.9 ) . CONCLUSIONS In patients with persistent AF , who underwent an anatomical approach , electrophysiological confirmation of PV disconnection significantly increased the fluoroscopy and procedural times , without effect on the long-term outcomes BACKGROUND Pulmonary veins ( PVs ) have been shown to represent the most frequent sites of ectopic beats initiating paroxysmal atrial fibrillation ( AF ) . However , additional non-PV triggers , arising from different areas , have been reported as well . One of the most common non-PV sites described is the superior vena cava . AIMS The purpose of the study was to investigate the impact result ing from the systematic isolation of the superior vena cava ( SVCI ) in addition to pulmonary vein antrum isolation ( PVAI ) on the outcome of paroxysmal , persistent , and permanent AF ablation . METHODS A total of 320 consecutive patients who had been referred to our center in order to undergo a first attempt of AF ablation were r and omized into 2 groups . Group I ( 160 patients ) underwent PVAI only ; Group II ( 160 patients ) underwent PVAI and SVCI . RESULTS AF was paroxysmal in 134 ( 46 % ) , persistent in 75 ( 23 % ) , and permanent in 111 ( 31 % ) of said patients . SVCI was performed on 134 of the 160 patients ( 84 % ) in Group II . SVC isolation was not performed on the remaining 26 patients either because of phrenic nerve capture or the lack of SVC potentials . Comparison of the outcome data between the 2 groups , after a follow-up of 12 months , revealed a significant difference in total procedural success solely with patients manifesting paroxysmal atrial fibrillation ( 56/73 [ 77 % ] Group I vs. 55/61 [ 90 % ] Group II ; P = 0.04 ; OR 2.78 ) . CONCLUSIONS In our study , the strategy of the empiric SVCI in addition to PVAI has improved the outcome of AF ablation solely in patients manifesting paroxysmal AF BACKGROUND Left atrial ( LA ) circumferential ablation has been reported to eliminate atrial fibrillation ( AF ) . Whether an ablation without encirclement of the pulmonary veins ( PVs ) is as effective as LA circumferential ablation is not clear . OBJECTIVES The purpose of this study was to compare the efficacy of LA circumferential ablation and nonencircling linear ablation in patients with chronic AF . METHODS Eighty patients with chronic AF were r and omized to undergo LA circumferential ablation ( n = 40 ) or nonencircling linear ablation ( n = 40 ) . In LA circumferential ablation , the PVs were encircled , with additional lines made in the mitral isthmus and posterior wall or roof . In nonencircling linear ablation , 4 + /- 1 ablation lines were created through areas of complex electrograms , with lines in the roof ( 38 ) , anterior wall ( 36 ) , septum ( 40 ) , mitral isthmus ( 32 ) , and posterior annulus ( 6 ) . The endpoint of LA circumferential ablation and nonencircling linear ablation was voltage abatement . RESULTS LA flutter occurred in 15 % after LA circumferential ablation and in 18 % after nonencircling linear ablation ( P = .8 ) . A repeat ablation procedure was performed for recurrent AF in 7 and 11 patients or for atrial flutter in 6 and 4 patients after LA circumferential ablation and nonencircling linear ablation , respectively ( P = .8 ) . At 9 + /- 4 months , the prevalence of AF was 28 % in the LA circumferential ablation and 25 % in the nonencircling linear ablation group ( P = .8 ) . Sixty-eight percent and 60 % of patients were in sinus rhythm and free of AF and atrial flutter in the absence of antiarrhythmic drug therapy after LA circumferential ablation and nonencircling linear ablation , respectively ( P = .5 ) . There were no complications . CONCLUSION Nonencircling linear ablation and LA circumferential ablation are equally efficacious in eliminating chronic AF . However , the advantage of nonencircling linear ablation is that it eliminates the need for ablation along the posterior wall of the LA . Therefore , nonencircling linear ablation may avoid the small but real risk of atrioesophageal fistula formation associated with LA circumferential ablation BACKGROUND This prospect i ve multicenter r and omized study aim ed to compare the efficacy of 3 common ablation methods used for longst and ing permanent atrial fibrillation ( AF ) . METHODS A total of 144 patients with longst and ing permanent AF ( median duration 28 months ) were r and omly assigned to circumferential pulmonary vein ablation ( CPVA , group 1 , n = 47 ) , to pulmonary vein antrum isolation ( PVAI , group 2 , n = 48 ) or to a hybrid strategy combining ablation of complex fractionated or rapid atrial electrograms ( CFAE ) in both atria followed by a pulmonary vein antrum isolation ( CFAE + PVAI , group 3 , n = 49 ) . RESULTS Scarring in the left atrium and structural heart disease/hypertension were present in most patients ( 65 % ) . After a mean follow-up of 16 months , 11 % of patients in group 1 , 40 % of patients in group 2 and 61 % of patients in group 3 were in sinus rhythm after one procedure and with no antiarrhythmic drugs ( P < .001 ) . Sinus rhythm maintenance would increase respectively to 28 % ( group 1 ) , 83 % ( group 2 ) , and 94 % ( group 3 ) after 2 procedures and with antiarrhythmic drugs ( AADs , P < .001 ) . The AF terminated during ablation , either by conversion to sinus rhythm or organization into an atrial tachyarrhythmia , in 13 % of patients ( group 1 ) , 44 % ( group 2 ) , and 74 % ( group 3 ) respectively . CFAE alone , performed as the first step of the ablation in group 3 , organized AF in only 1 patient . CONCLUSION In this study , the hybrid AF ablation strategy including antrum isolation and CFAE ablation had the highest likelihood of maintaining sinus rhythm in patients with longst and ing permanent AF . Electrical isolation of the PVs , although inadequate if performed alone , is relevant to achieve long-term sinus rhythm maintenance after ablation . Bi-atrial CFAE ablation had a minimal impact on AF termination during ablation BACKGROUND Several studies have provided details of left atrial anatomy by means of the image integration techniques , particularly focusing on the atypical patterns of the pulmonary veins . OBJECTIVE To compare , in a prospect i ve , r and omized fashion , the conventional method of pulmonary vein disconnection and the image integration-guided approach . METHODS Two hundred and ninety consecutive patients ( 290 patients , mean age 55 + /- 11 years ) with drug-refractory paroxysmal or persistent atrial fibrillation were enrolled in the study and were divided into two treatment groups : group 1 ( 145 patients ) undergoing an imaging integration-guided ( CartoMerge TM ) ablation ; group 2 ( 145 patients ) treated by a conventional radiofrequency catheter ablation procedure .  The arrhythmia was refractory to at least two antiarrhythmic drugs ( IC , amiodarone )  . RESULTS Electrical disconnection of all identified pulmonary veins was obtained in all patients of both groups . Bidirectional block of the cavotricuspid isthmus was achieved in 34 group 1 patients and in 40 group 2 patients . Left mitral isthmus ablation was attempted in 52 group 1 patients and in 56 group 2 patients . At a mean follow-up of 14 + /- 12 months , the atrial fibrillation-free survival rate was significantly higher in group 1 patients compared with group 2 patients ( 88 % vs 69 % , P = 0.017 ) . The analysis for the subset of patients with previously ineffective ablation ( 98 patients : 52 group 1 patients and 46 group 2 patients ) showed a significantly lower recurrence rate in group 1 versus group 2 ( 19 % vs 48 % , P < 0.01 ) . CONCLUSIONS Our data indicate a superior efficacy of the image-integration guided catheter ablation of atrial fibrillation over the long term Background — Steerable sheath technology is design ed to facilitate catheter access , stability , and tissue contact in target sites of atrial fibrillation ( AF ) catheter ablation . We hypothesized that rhythm control after interventional AF treatment is more successful using a steerable as compared with a nonsteerable sheath access . Methods and Results — One hundred thirty patients with paroxysmal or persistent drug-refractory AF undergoing their first ablation procedure were prospect ively included in a r and omized fashion in 2 centers .  Ablation was performed by 10 operators with different levels of clinical experience . Treatment outcome was measured with serial 7-day Holter ECGs and additional symptom-based arrhythmia documentation . Single procedure success ( freedom from AF and /or atrial macroreentrant tachycardia ) was significantly higher in patients ablated with a steerable sheath ( 78 % versus 55 % after 3 months , P=0.005 ; 76 % versus 53 % after 6 months , P=0.008 ) . Rate of pulmonary vein isolation , procedure duration , and radiofrequency application time did not differ significantly , whereas fluoroscopy time was lower in the steerable sheath group ( 33±14 minutes versus 45±17 minutes , P<0.001 ) . Complication rates showed no significant difference ( 3.2 % versus 5 % , P=0.608 ) . On multivariable analysis , steerable sheath usage remained the only powerful predictor for rhythm outcome after 6 months of follow-up ( hazard ratio , 2.837 [ 1.197 to 6.723 ] ) . Conclusions — AF catheter ablation using a manually controlled , steerable sheath for catheter navigation result ed in a significantly higher clinical success rate , with comparable complication rates and with a reduction in periprocedural fluoroscopy time . Clinical Trial Registration — URL : http:// clinical trials.gov . Unique identifier : NCT00469638 Objective To determine whether or not radiofrequency ablation ( RFA ) for persistent atrial fibrillation in patients with advanced heart failure leads to improvements in cardiac function . Setting Patients were recruited from heart failure outpatient clinics in Scotl and . Design and intervention Patients with advanced heart failure and severe left ventricular dysfunction were r and omised to RFA ( rhythm control ) or  continued medical treatment  ( rate control ) . Patients were followed up for a minimum of 6 months . Main outcome measure Change in left ventricular ejection fraction ( LVEF ) measured by cardiovascular MRI . Results 22 patients were r and omised to RFA and 19 to medical treatment . In the RFA group , 50 % of patients were in sinus rhythm at the end of the study ( compared with none in the medical treatment group ) . The increase in cardiovascular magnetic resonance ( CMR ) LVEF in the RFA group was 4.5±11.1 % compared with 2.8±6.7 % in the medical treatment group ( p=0.6 ) . The RFA group had a greater increase in radionuclide LVEF ( a prespecified secondary end point ) than patients in the medical treatment group ( + 8.2±12.0 % vs + 1.4±5.9 % ; p=0.032 ) . RFA did not improve N-terminal pro-B-type natriuretic peptide , 6 min walk distance or quality of life . The rate of serious complications related to RFA was 15 % . Conclusions RFA result ed in long-term restoration of sinus rhythm in only 50 % of patients . RFA did not improve CMR LVEF compared with a strategy of rate control . RFA did improve radionuclide LVEF but did not improve other secondary outcomes and was associated with a significant rate of serious complications . Clinical trials registration number NCT00292162 BACKGROUND Catheter ablation of complex fractionated atrial electrograms ( CFAE ) for persistent atrial fibrillation ( AF ) is a promising treatment strategy . We tested the hypothesis that CFAE ablation is superior to linear ablation in patients with persistent or long-st and ing persistent AF . METHODS In this study , 116 patients with persistent AF were r and omly assigned to undergo circumferential PVI plus additional lines ( linear ablation group ; 59 patients ) or CFAE ablation plus ostial pulmonary vein isolation ( PVI ) ( spot ablation group ; 57 patients ) . Primary endpoint was freedom from atrial tachyarrhythmia after a single ablation procedure ( clinical and repeat 7-day Holter ) , 12 months after ablation without antiarrhythmic medication . RESULTS The primary endpoint was reached in 22 of 59 ( 37 % ) patients of the linear ablation group and in 22 of 57 ( 39 % ) patients of the spot ablation group ( P = 0.9 ) . Freedom from atrial tachyarrhythmias , including reablations , was achieved in 54 % of patients ( linear ablation group ) versus 56 % of patients ( spot ablation group ; P = 0.8 ) . The incidence of recurrent persistent AF was higher after linear ablation than after spot ablation ( 21/37 vs 11/35 patients ; P = 0.03 ) ; atrial tachycardia ( AT ) was seen more often after spot ablation ( 10/35 vs 4/37 patients ; P = 0.03 ) . CONCLUSION In patients with persistent AF , CFAE ablation plus PVI reaches the same results as circumferential PVI plus lines , in terms of freedom from symptomatic atrial tachyarrhythmias within the first year after a single ablation procedure . Arrhythmia recurrences in patients after spot ablation were caused more often by AT , whereas recurrent persistent AF was more prevalent after the linear ablation approach Background Catheter ablation ( CA ) is a highly effective therapy for the treatment of paroxysmal atrial fibrillation ( AF ) when compared with antiarrhythmic drug therapy ( ADT ) . No r and omized studies have compared the two strategies in persistent AF . The present r and omized trial aim ed to compare the effectiveness of CA vs. ADT in treating persistent AF . Methods and results Patients with persistent AF were r and omly assigned to CA or ADT ( excluding patients with long-st and ing persistent AF ) . Primary endpoint at 12-month follow-up was defined as any episode of AF or atrial flutter lasting > 24 h that occurred after a 3-month blanking period . Secondary endpoints were any atrial tachyarrhythmia lasting > 30 s , hospitalization , and electrical cardioversion . In total , 146 patients were included ( aged 55 ± 9 years , 77 % male ) . The ADT group received class Ic ( 43.8 % ) or class III drugs ( 56.3 % ) . In an intention-to-treat analysis , 69 of 98 patients ( 70.4 % ) in the CA group and 21 of 48 patients ( 43.7 % ) in the ADT group were free of the primary endpoint ( P = 0.002 ) , implying an absolute risk difference of 26.6 % ( 95 % CI 10.0–43.3 ) in favour of CA . The proportion of patients free of any recurrence ( > 30 s ) was higher in the CA group than in the ADT group ( 60.2 vs. 29.2 % ; P < 0.001 ) and cardioversion was less frequent ( 34.7 vs. 50 % , respectively ; P = 0.018 ) . Conclusion Catheter ablation is superior to medical therapy for the maintenance of sinus rhythm in patients with persistent AF at 12-month follow-up . Clinical Trial Registration Information NCT00863213 ( http:// clinical trials.gov/ct2/show/NCT00863213 ) Background — Together with pulmonary veins , many extrapulmonary vein areas may be the source of initiation and maintenance of atrial fibrillation . The left atrial appendage ( LAA ) is an underestimated site of initiation of atrial fibrillation . Here , we report the prevalence of triggers from the LAA and the best strategy for successful ablation . Methods and Results — Nine hundred eighty-seven consecutive patients ( 29 % paroxysmal , 71 % nonparoxysmal ) undergoing redo catheter ablation for atrial fibrillation were enrolled . Two hundred sixty-six patients ( 27 % ) showed firing from the LAA and became the study population . In 86 of 987 patients ( 8.7 % ; 5 paroxysmal , 81 nonparoxysmal ) , the LAA was found to be the only source of arrhythmia with no pulmonary veins or other extrapulmonary vein site reconnection . Ablation was performed either with focal lesion ( n=56 ; group 2 ) or to achieve LAA isolation by placement of the circular catheter at the ostium of the LAA guided by intracardiac echocardiography ( 167 patients ; group 3 ) . In the remaining patients , LAA firing was not ablated ( n=43 ; group 1 ) . At the 12±3-month follow-up , 32 patients ( 74 % ) in group 1 had recurrence compared with 38 ( 68 % ) in group 2 and 25 ( 15 % ) in group 3 ( P<0.001 ) . Conclusions — The LAA appears to be responsible for arrhythmias in 27 % of patients presenting for repeat procedures . Isolation of the LAA could achieve freedom from atrial fibrillation in patients presenting for a repeat procedure when arrhythmias initiating from this structure are demonstrated BACKGROUND We conducted a r and omized , controlled trial of circumferential pulmonary-vein ablation for the treatment of chronic atrial fibrillation . METHODS A total of 146 patients with a mean ( + /-SD ) age of 57+/-9 years who had chronic atrial fibrillation were r and omly assigned to receive amiodarone and undergo two cardioversions during the first three months alone ( the control group ) or in combination with circumferential pulmonary-vein ablation . Cardiac rhythm was assessed with daily telephonic transmissions for one year . The left atrial diameter and the severity of symptoms were assessed at 12 months . RESULTS Among the 77 patients assigned to undergo circumferential pulmonary-vein ablation , ablation was repeated because of recurrent atrial fibrillation in 26 percent of patients and atypical atrial flutter in 6 percent . An intention-to-treat analysis showed that 74 percent of patients in the ablation group and 58 percent of those in the control group were free of recurrent atrial fibrillation or flutter without antiarrhythmic-drug therapy at one year ( P=0.05 ) . Among the 69 patients in the control group , 53 ( 77 percent ) crossed over to undergo circumferential pulmonary-vein ablation for recurrent atrial fibrillation by one year and only 3 ( 4 percent ) were in sinus rhythm without antiarrhythmic-drug therapy or ablation . There were significant decreases in the left atrial diameter ( 12+/-11 percent , P<0.001 ) and the symptom severity score ( 59+/-21 percent , P<0.001 ) among patients who remained in sinus rhythm after circumferential pulmonary-vein ablation . Except for atypical atrial flutter , there were no complications attributable to circumferential pulmonary-vein ablation . CONCLUSIONS Sinus rhythm can be maintained long term in the majority of patients with chronic atrial fibrillation by means of circumferential pulmonary-vein ablation independently of the effects of antiarrhythmic-drug therapy , cardioversion , or both . The maintenance of sinus rhythm is associated with a significant decrease in both the severity of symptoms and the left atrial diameter Aims This multicentre , r and omized trial compared three strategies of AF ablation : ablation of complex fractionated electrograms ( CFE ) alone , pulmonary vein isolation ( PVI ) alone , and combined PVI + CFE ablation , using st and ardized automated mapping software . Methods and results Patients with drug-refractory , high-burden paroxysmal ( episodes > 6 h , > 4 in 6 months ) or persistent atrial fibrillation ( AF ) were enrolled at eight centres . Patients ( n = 100 ) were r and omized to one of three arms . For CFE alone ( n = 34 ) , spontaneous/induced AF was mapped using vali date d , automated CFE software and all sites < 120 ms were ablated until AF termination/non-inducibility . For PVI ( n = 32 ) , all four PV antra were isolated and confirmed using a circular catheter . For PVI + CFE ( n = 34 ) , all four PV antra were isolated , followed by AF induction and ablation of all CFE sites until AF termination/non-inducibility . Patients were followed at 3 , 6 , and 12 months with a visit , ECG , 48 h Holter . Atrial fibrillation symptoms were confirmed by loop recording . Repeat procedures were allowed within the first 6 months . The primary endpoint was freedom from AF > 30 s at 1 year . Patients ( age 57 ± 10 years , LA size 42 ± 6 mm ) were 35 % persistent AF . In CFE , ablation terminated AF in 68 % . Only 0.4 PVs per patient were isolated as a result of CFE . In PVI , 94 % had all four PVs successfully isolated . In PVI + CFE , 94 % had all four PVs isolated , 76 % had inducible AF with additional CFE ablation , with 73 % termination of AF . There were significantly more repeat procedures in the CFE arm ( 47 % ) vs. PVI ( 31 % ) or PVI + CFE ( 15 % ) ( P = 0.01 ) . After one procedure , PVI + CFE had a significantly higher freedom from AF ( 74 % ) compared with PVI ( 48 % ) and CFE ( 29 % ) ( P = 0.004 ) . After two procedures , PVI + CFE still had the highest success ( 88 % ) compared with PVI ( 68 % ) and CFE ( 38 % ) ( P = 0.001 ) . Ninety-six percent of these patients were off anti-arrhythmics . Complications were two tamponades , no PV stenosis , and no mortality . Conclusion In high-burden paroxysmal/persistent AF , PVI + CFE has the highest freedom from AF vs. PVI or CFE alone after one or two procedures . Complex fractionated electrogram alone has the lowest one and two procedure success rates with a higher incidence of repeat procedures . Clinical Trials.gov identifier number NCT00367757 OBJECTIVES We hypothesized that human atrial fibrillation ( AF ) may be sustained by localized sources ( electrical rotors and focal impulses ) , whose elimination ( focal impulse and rotor modulation [ FIRM ] ) may improve outcome from AF ablation . BACKGROUND Catheter ablation for AF is a promising therapy , whose success is limited in part by uncertainty in the mechanisms that sustain AF . We developed a computational approach to map whether AF is sustained by several me and ering waves ( the prevailing hypothesis ) or localized sources , then prospect ively tested whether targeting patient-specific mechanisms revealed by mapping would improve AF ablation outcome . METHODS We recruited 92 subjects during 107 consecutive ablation procedures for paroxysmal or persistent ( 72 % ) AF . Cases were prospect ively treated , in a 2-arm 1:2 design , by ablation at sources ( FIRM-guided ) followed by conventional ablation ( n = 36 ) , or conventional ablation alone ( n = 71 ; FIRM-blinded ) . RESULTS Localized rotors or focal impulses were detected in 98 ( 97 % ) of 101 cases with sustained AF , each exhibiting 2.1 ± 1.0 sources . The acute endpoint ( AF termination or consistent slowing ) was achieved in 86 % of FIRM-guided cases versus 20 % of FIRM-blinded cases ( p < 0.001 ) . FIRM ablation alone at the primary source terminated AF in a median 2.5 min ( interquartile range : 1.0 to 3.1 min ) . Total ablation time did not differ between groups ( 57.8 ± 22.8 min vs. 52.1 ± 17.8 min , p = 0.16 ) . During a median 273 days ( interquartile range : 132 to 681 days ) after a single procedure , FIRM-guided cases had higher freedom from AF ( 82.4 % vs. 44.9 % ; p < 0.001 ) after a single procedure than FIRM-blinded cases with rigorous , often implanted , electrocardiography monitoring . Adverse events did not differ between groups . CONCLUSIONS Localized electrical rotors and focal impulse sources are prevalent sustaining mechanisms for human AF . FIRM ablation at patient-specific sources acutely terminated or slowed AF , and improved outcome . These results offer a novel mechanistic framework and treatment paradigm for AF . ( Conventional Ablation for Atrial Fibrillation With or Without Focal Impulse and Rotor Modulation [ CONFIRM ] ; NCT01008722 ) OBJECTIVES This study sought to determine whether ablation of complex fractionated atrial electrograms ( CFAEs ) after antral pulmonary vein isolation ( APVI ) further improves the clinical outcome of APVI in patients with long-lasting persistent atrial fibrillation ( AF ) . BACKGROUND Ablation of CFAEs has been reported to eliminate persistent AF . However , residual pulmonary vein arrhythmogenicity is a common mechanism of recurrence . METHODS In this r and omized study , 119 consecutive patients ( mean age 60 + /- 9 years ) with long-lasting persistent AF underwent APVI with an irrigated-tip radiofrequency ablation catheter . Antral pulmonary vein isolation result ed in termination of AF in 19 of 119 patients ( Group A , 16 % ) . The remaining 100 patients who still were in AF were r and omized to no further ablation and underwent cardioversion ( Group B , n = 50 ) or to ablation of CFAEs in the left atrium or coronary sinus for up to 2 additional hours of procedure duration ( Group C , n = 50 ) . RESULTS Atrial fibrillation terminated during ablation of CFAEs in 9 of 50 patients ( 18 % ) in Group C. At 10 + /- 3 months after a single ablation procedure , 18 of 50 ( 36 % ) in Group B and 17 of 50 ( 34 % ) in Group C were in sinus rhythm without antiarrhythmic drugs ( p = 0.84 ) . In Group A , 15 of 19 patients ( 79 % ) were in sinus rhythm . A repeat ablation procedure was performed in 34 of 100 r and omized patients ( for AF in 30 and atrial flutter in 4 ) . At 9 + /- 4 months after the final procedure , 34 of 50 ( 68 % ) in Group B and 30 of 50 ( 60 % ) in Group C were in sinus rhythm without antiarrhythmic drugs ( p = 0.40 ) . CONCLUSIONS Up to 2 h of additional ablation of CFAEs after APVI does not appear to improve clinical outcomes in patients with long-lasting persistent AF BACKGROUND The deployment of an ablation line connecting the left inferior PV to the mitral annulus ( mitral isthmus line [ MIL ] ) enhances the efficacy of pulmonary vein disconnection ( PVD ) in preventing atrial fibrillation ( AF ) recurrences . OBJECTIVES To investigate the long-term effect of the additional linear lesion in a prospect i ve r and omized study . METHODS One hundred and eighty-seven patients ( 37 females , mean age : 55 + /- 11 years ) with paroxysmal ( 126 ) or persistent ( 61 patients ) AF , were prospect ively r and omized into two groups : PVD ( group A , 92 patients ) or PVD combined with MIL ( group B , 95 patients ) , performed by means of an irrigated-tip ablation catheter . RESULTS Successful disconnection of all PVs was achieved in all patients . A bidirectional block ( BB ) along the left atrial isthmus was obtained in 72 of 95 ( 76 % ) patients in group B , most of whom required additional RF pulses from within the distal CS . A transient ischemic attack occurred in 1 patient of group A , and a cardiac tamponade occurred in 1 patient of group B. At 1 year , 53 + /- 5 % ( group A ) and 71 + /- 5 % ( group B ) remained arrhythmia free ( P = 0.01 ) ; subgroup analysis highlights a higher improvement among patients with persistent AF ( 74 + /- 9 % vs 36 + /- 9 % ; P < 0.01 ) than what was observed in paroxysmal AF ( 76 + /- 6 % vs 62 + /- 6 % ; P < 0.05 ) ; antiarrhythmic drugs were continued in 56 % and 50 % , respectively , in groups A and B ( P = ns ) . CONCLUSIONS The addition of mitral isthmus line to the PV disconnection allows a significant improvement of sinus rhythm maintenance rate , particularly in patients with persistent AF , without the risk for major complications BACKGROUND The limited efficacy and complications of segmental ostial pulmonary vein isolation ( PVI ) for treating atrial fibrillation ( AF ) have been discussed so , in the present study the feasibility and efficiency of performing segmental pulmonary vein ( PV ) antrum isolation to treat AF were assessed . METHODS AND RESULTS A total of 187 patients with drug-refractory AF ( paroxysmal 120 , persistent 67 ) underwent segmental PVI guided by circumferential 20-electrode catheters ( Lasso ) . Radiofrequency ( RF ) current was delivered either at the ostium using a regular Lasso ( 15 - 20 mm in diameter , 70 patients : Group 1 ) or at the antrum using a larger Lasso ( 25 - 30 mm in diameter , 117 patients : Group 2 ) . A significantly wider region had to be ablated , with a longer RF application time , to isolate all 4 PVs in Group 2 patients than in Group 1 patients . Although the rate of recurrence of AF after the initial session was equal in both groups , a significantly greater number of patients were free from AF after a mean of 1.4 procedures in Group 2 than in Group 1 ( 93 % vs 76 % for paroxysmal AF , 78 % vs 48 % for persistent AF ) . CONCLUSIONS Segmental antral PVI using large-sized Lasso catheters was found to be more effective and safer than ostial PVI for the treatment of AF AIMS We conducted a multi-centre , prospect i ve , controlled , r and omized trial to investigate the adjunctive role of ablation therapy to antiarrhythmic drug therapy in preventing  atrial fibrillation ( AF )  relapses in patients with paroxysmal or persistent AF in whom antiarrhythmic drug therapy had already failed . METHODS AND RESULTS One hundred and thirty seven patients were r and omized to ablation and antiarrhythmic drug therapy ( ablation group ) or antiarrhythmic drug therapy alone ( control group ) . In the ablation group , patients underwent cavo-tricuspid and left inferior pulmonary vein (PV)-mitral isthmus ablation plus circumferential PV ablation . The primary end-point of the study was the absence of any recurrence of atrial arrhythmia lasting > 30 s in the 1-year follow-up period , after 1-month blanking period . Three ( 4.4 % ) major complications were related to ablation : one patient had a stroke during left atrium ablation , another suffered transient phrenic paralysis , and the third had a pericardial effusion which required pericardiocentesis . After 12 months of follow-up , 63/69 ( 91.3 % ) control group patients had at least one AF recurrence , whereas 30/68 ( 44.1 % ) ( P<0.001 ) ablation group patients had atrial arrhythmia recurrence ( four patients had atrial flutter , 26 patients AF ) . CONCLUSION Ablation therapy combined with antiarrhythmic drug therapy is superior to antiarrhythmic drug therapy alone in preventing atrial arrhythmia recurrences in patients with paroxysmal or persistent AF in whom antiarrhythmic drug therapy has already failed Background — The single-procedure efficacy of pulmonary vein isolation ( PVI ) is less than optimal in patients with persistent atrial fibrillation ( AF ) . Adjunctive techniques have been developed to enhance single-procedure efficacy in these patients . We conducted a study to compare 3 ablation strategies in patients with persistent AF . Methods and Results — Subjects were r and omized as follows : arm 1 , PVI + ablation of non-PV triggers identified using a stimulation protocol ( st and ard approach ) ; arm 2 , st and ard approach + empirical ablation at common non-PV AF trigger sites ( mitral annulus , fossa ovalis , eustachian ridge , crista terminalis , and superior vena cava ) ; or arm 3 , st and ard approach + ablation of left atrial complex fractionated electrogram sites . Patients were seen at 6 weeks , 6 months , and 1 year ; transtelephonic monitoring was performed at each visit . Antiarrhythmic drugs were discontinued at 3 to 6 months . The primary study end point was freedom from atrial arrhythmias off antiarrhythmic drugs at 1 year after a single-ablation procedure . A total of 156 patients ( aged 59±9 years ; 136 males ; AF duration , 47±50 months ) participated ( arm 1 , 55 patients ; arm 2 , 50 patients ; arm 3 , 51 patients ) . Procedural outcomes ( procedure , fluoroscopy , and PVI times ) were comparable between the 3 arms . More lesions were required to target non-PV trigger sites than a complex fractionated electrogram ( 33±9 versus 22±9 ; P<0.001 ) . The primary end point was achieved in 71 patients and was worse in arm 3 ( 29 % ) compared with arm 1 ( 49 % ; P=0.04 ) and arm 2 ( 58 % ; P=0.004 ) . Conclusions — These data suggest that additional substrate modification beyond PVI does not improve single-procedure efficacy in patients with persistent AF . Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT00379301 Objective Whether early rhythm suppression with extensive antiarrhythmic drugs ( AADs ) in persistent atrial fi brillation ( AF ) after catheter ablation decreases arrhythmia recurrence is unknown . We now report the 12-month follow-up data in this prospect i ve and r and omized study . Methods and results 123 consecutive patients with persistent AF undergoing catheter ablation were r and omly divided into an extensive AADs therapy group ( group 1 : 62 patients using both class Ic and III AADs ) or one AAD therapy group ( group 2 : 61 patients using class Ic or III AADs alone ) for the initial 2 months after ablation . Recurrence of atrial tachyarrhythmias ( ATa ) was valuated at both 2 months and 12 months following ablation . During the fi rst 2 months after ablation , less ATa were found in group 1 compared with group 2 ( 17/62 versus 29/61 , P= 0.021 ) . However , there was no diff erence with regard to ATa at 12 months between the groups ( 21/62 versus 22/61 , P= 0.799 ) . ATa at 2 months and left atrial diameter ( LAD ) were the statistically signifi ca nt predictors of ATa during 12-month follow-up . Conclusions While use of extensive AADs within the initial 2 months after persistent AF ablation decreases early ATa , it does not prevent late ATa . Moreover , LAD as well as early ATa is a strong predictor of ATa at 12 months BACKGROUND High-frequency stimulation ( HFS ) of the atria induces atrial fibrillation ( AF ) when applied during sinus rhythm and elicits a parasympathetic response when delivered at sites where ganglionated plexi ( GPs ) are located . However , little is known about its impact after an electrophysiological study . OBJECTIVE To evaluate the impact of HFS on the short-term and long-term outcomes after the ablation of persistent AF . METHODS Thirty consecutive patients with persistent or long-st and ing persistent AF were r and omly assigned to either receive HFS of the left atrium ( n = 15 ) or not ( n = 15 ) during their electrophysiological studies . Patients receiving HFS were examined to determine whether or not a vagal response was elicited by the HFS at sites where GPs were located before and after conventional pulmonary vein isolation without any ablation targeting the GPs . Patients not receiving the HFS underwent the ablation procedure alone . The rate of recurrence of AF within 3 months of the procedure ( early recurrence [ ER ] ) and the frequency of that occurring after that period ( late recurrence ) were compared between the patient groups . RESULTS The incidence of ER occurred more frequently in patients with HFS than in those without ( 80 % vs 40 % ; P = .015 ) , whereas the occurrence of late recurrence was similar between the 2 groups ( 27 % vs 33 % ; P = .73 ) . In the HFS group , the number of GPs decreased from 3.4 ± 1.1 to 1.5 ± 0.8 after the pulmonary vein isolation ( P < .0001 ) , and the decrease was smaller in the patients experiencing ER than in those without . CONCLUSION HFS increases the incidence of ER in patients with persistent AF despite a partial GP modification result ing from the pulmonary vein isolation BACKGROUND The best method for performing atrial fibrillation ( AF ) ablation is still under debate . The importance of using a circular mapping ( CM ) catheter for assessing isolation of the pulmonary vein ( PV ) antrum on the outcome of the procedure has not been clearly established . OBJECTIVE The purpose of this study was to evaluate whether use of a CM catheter improves the arrhythmia-free proportion after circumferential pulmonary vein ablation ( CPVA ) . METHODS A series of 146 consecutive patients ( 83 % males , age 53 + /- 10 years , 53 % paroxysmal AF ) were r and omized to two ablation strategies . In both groups , ipsilateral PV encirclement was performed until disappearance or dissociation of the local electrogram within the surrounded area . In the first group , only the radiofrequency catheter was used to both map and ablate ( CPVA group , n = 73 ) . In the other group , a CM catheter was added to assess the electrical activity of the PV antrum ( CPVA-CM group , n = 73 ) . An ablation line along the left atrial roof was also created in all patients . RESULTS Procedural and fluoroscopic times were longer in the CPVA-CM group ( P < .05 ) . Severe procedure-related complications occurred in 1 ( 1.4 % ) patient in the CPVA group and in 3 ( 4.1 % ) patients in the CPVA-CM group ( P = .317 ) . After mean follow-up of 9 + /- 3 months , 31 ( 42.5 % ) patients in the CPVA group and 47 ( 64.4 % ) patients in the CPVA-CM group were arrhythmia-free without antiarrhythmic medication ( P = .008 ) . CONCLUSION Use of a CM catheter to ensure isolation of the PV antrum improved the success of CPVA but increased some procedural requirements AIMS Catheter positioning and stability are recognized challenges in catheter ablation of atrial fibrillation ( AF ) . This prospect i ve r and omized study assessed whether routinely using a steerable sheath affects procedure outcomes . METHODS AND RESULTS Fifty-six AF patients were r and omized to  ablation using either an Agilis NXT ( St Jude Medical , St Paul , MN , USA ) steerable sheath or a fixed-curve Mullins sheath ( Cook Medical Inc. , Bloomington , IN , USA ) for the ablation catheter . A mapping system with CT integration was used to isolate the pulmonary veins ( PVs ) in pairs and further ablation performed if AF persisted . There was no significant difference in time to gain trans-septal access , CT registration time , time to isolate PVs , fluoroscopy time for PV isolation , total procedure time , or total fluoroscopy time . A learning curve was seen for the steerable sheath , and after correcting for this , CT registration time and right PV isolation were quicker in this group . One patient crossed over from fixed-curve to steerable . Acute , 3- , and 6-month single procedure success were similar in both groups . CONCLUSION Allowing for the usage learning curve , a steerable sheath reduced time for some elements of AF ablation . Although this did not result in improved success , it may be useful for inexperienced operators , but at increased procedure cost Background —Ablation of the pulmonary veins ( PVs ) for atrial fibrillation treatment is often combined with linear radiofrequency lesions along the left atrium ( LA ) to improve the success rate . The study was design ed to assess the contribution of LA posterior wall isolation to the outcome of circumferential pulmonary vein ablation ( CPVA ) . Methods and Results —CPVA consisted of continuous radiofrequency lesions encircling both ipsilateral PVs plus an ablation line along the mitral isthmus . Patients were then r and omized into 2 groups . In the first group , superior PVs were connected by linear lesions along the LA roof ( CPVA-1 group ) . In the second group , the LA posterior wall was isolated by adding a second line connecting the inferior aspect of the 2 inferior PVs ( CPVA-2 group ) . The study included 120 patients ( 53±11 years , 77 % male , 60 % paroxysmal atrial fibrillation , LA of 41.3±5.4 mm , 46 % with hypertension , and 22 % with structural heart disease ) . After a single ablation procedure and a mean follow-up of 10±4 months , 24 ( 40 % ) patients of the CPVA-1 group had atrial fibrillation recurrences and 3 ( 5 % ) had new-onset LA flutter . In the CPVA-2  group , recurrences were due to atrial fibrillation episodes in 23 patients ( 38 % ) and LA flutter in 4 ( 7 % ) . Freedom from arrhythmia recurrences was not statistically different in the CPVA-1 group as compared with the CPVA-2 group ( log rank P=0.943 ) . Conclusion —Isolation of the LA posterior wall did not increase the success rate of CPVA OBJECTIVES The aim of this study was to compare -- in patients with persistent and permanent atrial fibrillation (AF)--the  efficacy and safety of left atrial ablation with that of a biatrial approach . BACKGROUND Left atrium-based catheter ablation of AF , although very effective in the paroxysmal form of the arrhythmia , has an insufficient efficacy in patients with persistent and permanent AF . METHODS Eighty highly symptomatic patients ( age , 58.6 + /- 8.9 years ) with persistent ( n = 43 ) and permanent AF ( n = 37 ) , refractory to antiarrhythmic drugs , were r and omized to two different ablation approaches guided by electroanatomical mapping . A procedure including circumferential pulmonary vein , mitral isthmus , and cavotricuspid isthmus ablation was performed in 41 cases ( left atrial ablation group ) . In the remaining 39 patients ( biatrial ablation group ) , the aforementioned approach was integrated by the following lesions in the right atrium : intercaval posterior line , intercaval septal line , and electrical disconnection of the superior vena cava . RESULTS During follow-up ( mean duration 14 + /- 5 months ) , AF recurred in 39 % of patients in the left atrial ablation group and in 15 % of patients in the biatrial ablation group ( p = 0.022 ) . Multivariable Cox regression analysis showed that ablation technique was an independent predictor of AF recurrence during follow-up . CONCLUSIONS In patients with persistent and permanent AF , circumferential pulmonary vein ablation , combined with linear lesions in the right atrium , is feasible , safe , and has a significantly higher success rate than left atrial and cavotricuspid ablation alone BACKGROUND Although mitral isthmus ( MI ) ablation in atrial fibrillation ( AF ) patients has been shown to be an effective ablative strategy , the establishment of the bidirectional conduction block of the MI is technically challenging . We investigated the usefulness of a steerable sheath for MI ablation in patients with persistent AF and its impact on the clinical outcome of persistent AF ablation . METHODS A total of 80 consecutive patients undergoing MI ablation  were r and omized to 1 of the following 2 groups : group S ( using a steerable long sheath ) or group NS ( using a nonsteerable long sheath ) . MI ablation was performed by using an open-irrigated ablation catheter with the guidance of a 3-dimensional mapping system . The endpoint of the MI ablation was the achievement of a bidirectional block . RESULTS Bidirectional block through the MI was achieved in 87.5 % ( 70/80 ) of patients with 14.0 ± 6.7 minutes of radiofrequency application . The bidirectional block was more frequently achieved in patients in group S compared to group NS ( 97.5 % ( 39/40 ) vs 77.5 % ( 31/40 ) , P = 0.02 ) . Additionally , epicardial ablation within the coronary sinus was less frequently required in group S compared to group NS ( 12.5 % ( 5/40 ) vs 72.5 % ( 29/40 ) , P < 0.0001 ) . Atrial tachycardia after the procedure more frequently occurred in the patients in whom MI block had not been achieved during the initial procedure ( 40.0 % ( 4/10 ) vs 10.0 % ( 7/70 ) , P = 0.04 ) . CONCLUSIONS The MI block could be achieved in the majority of patients by using a steerable sheath . An incomplete MI block increased the risk of AT following persistent AF ablation BACKGROUND A detailed appreciation of left atrial/pulmonary vein ( LA/PV ) anatomy may be important in improving the safety and success of catheter ablation ( CA ) for atrial fibrillation ( AF ) . OBJECTIVES The aim of this nonr and omized study was to determine the impact of computerized tomography ( CT ) image integration into a 3-dimensional ( 3D ) mapping system on the clinical outcome of patients undergoing CA for AF . METHODS Ninety-four patients ( age : 56 + /- 10 years ) with AF ( paroxysmal 46 , persistent 48 ) underwent wide encirclement of ipsilateral PV pairs using irrigated radiofrequency ablation with the endpoint of electrical isolation . Ablation was guided by 3D mapping alone ( electroanatomic 24 , noncontact 23 ) in 47 ( 3DM group ) patients and by CT image integration ( Cartomerge ) in 47 ( CT group ) . In persistent AF , a combination of linear ablation and targeted ablation of complex fractionated electrograms was also performed . RESULTS Successful PV electrical isolation did not differ between the two groups . A significant reduction in fluoroscopy times was demonstrated in the CT group ( 49 + /- 27 minutes vs 3DM group 62 + /- 26 minutes , P = 0.03 ) . Arrhythmia recurrence was reduced in the CT group ( 32 % vs 51 % in the 3DM group , P < 0.01 ) . In 30 symptomatic patients ( 12 CT and 18 3DM ) , repeat procedures for AF ( 13 in 3DM and 5 CT , P < or = 0.10 ) and AT ( 5 in 3DM and 7 CT , P = NS ) were performed . Overall success on 7-day monitor off antiarrhythmic drugs was achieved in 60 % in the 3DM group when compared with 83 % in the CT group ( P < 0.05 ) at a follow-up of 25 + /- 5 weeks . CONCLUSION CA for AF guided by CT integration was associated with reduced fluoroscopy times , arrhythmia recurrence , and increased restoration of sinus rhythm . Improved visualization of complex LA geometries might improve the safety and success of CA for AF BACKGROUND The efficacy of ablation of complex fractionated atrial electrograms ( CFEs ) in the single ablation procedure for nonparoxysmal atrial fibrillation ( AF ) patients is not well demonstrated . The aim of this study was to compare the ablation strategies of pulmonary vein isolation ( PVI ) plus linear ablation with and without additional ablation ofCFEs in these patients . METHODS Consecutive 60 patients ( 49 + /- 11 years old , 50 male , 10 female ) with nonparoxysmal AF underwent catheter ablation guided by a NavX mapping system .  A stepwise approach included a circumferential PVI and left atrial ( LA ) linear ablation followed by either the additional ablation of continuous CFEs in the LA/coronary sinus ( the first 30 patients ) or not ( the second 30 patients ) , detected by an automatic algorithm . RESULTS There was no difference in the baseline characteristics between the two groups . Complete PVI eliminated some continuous CFEs and altered the distribution of CFEs . Following PVI and linear ablation , the remaining continuous CFEs were identified in 7.9 + /-10 % mapping sites of the LA and CS , and were ablated successfully with a procedural AF termination rate of 53 % . With a follow-up of 19 + /-11 months , a Kaplan-Meier analysis showed that the patients with additional ablation of the CFEs had a higher rate of sinus rhythm maintenance . Multivariate analysis showed the single procedure success could be predicted by the procedural AF termination and the additional ablation of continuous CFEs in the LA/CS . CONCLUSIONS Ablation of continuous CFEs after PVI and LA linear ablation had a better long-term efficacy based on the results of single-ablation procedure Objective — Additional septal linear ablation in patients undergoing ablation of long-st and ing persistent atrial fibrillation ( AF ) could be beneficial due to additional extensive atrial tissue ablation and incidental ablation of sites with complex fractionated electrograms . We assessed the long-term outcome of patients after ablation of long-st and ing persistent AF with an additional left atrial ( LA ) septal line . Methods — Thirty-four patients were included . The patients were r and omized into two groups and underwent pulmonary vein ( PV ) isolation with roof line , mitral isthmus line and coronary sinus ablation . In group 1 an additional LA septal line was created . Results — AF converted into atrial tachycardia in 2 patients during septal ablation in group 1 . In group 2 AF terminated via atrial tachycardia in 3 patients ( P = ns ) . During a mean follow-up of 620 ± 119 days , 7 ( 41 % ) and 8 ( 47 % ) patients from group 1 and group 2 were free from recurrences ( P = ns ) . Redo procedures were performed in 5 patients of group 1 and in 5 patients of group 2 . For a follow-up of 349 ± 273 days after the last ablation , Cox ’s F-test showed a trend of more recurrences in group 1 ( P = 0.07 ) . Conclusions — In patients with long-st and ing AF , an additional LA septal linear ablation is not associated with a significantly higher AF termination rate . A septal linear lesion might increase the risk of septal reentrant tachycardias , and is associated with a trend towards a worse outcome BACKGROUND Left lateral mitral isthmus ( LLMI ) ablation achieves a low percentage of bidirectional conduction block in atrial fibrillation ( AF ) ablation . OBJECTIVE The purpose of this study was to investigate whether linear ablation through the lowest voltage area on the left atrial anterior wall ( LAAW ) can lead to better clinical outcomes compared to LLMI ablation . METHODS We obtained high-density three-dimensional ( 3D ) voltage mapping ( CARTO ) of the LA in 29 patients with persistent AF and determined the area of low voltage . In the multicenter prospect i ve study , clinical outcomes of LAAW ( n = 100 ) and LLMI ablations ( n = 100 ) were compared in patients with persistent AF ( 79.4 % male , 59.4 ± 10.6 years ) . RESULTS ( 1 ) The low-voltage area consistently existed on LAAW and had a correlation with the LA-aorta contact area ( R = 0.921 , P < .0001 ) . Mean voltage of LAAW was significantly lower than that of LLMI ( P < .0001 ) . ( 2 ) The length of LAAW ablation ( 37.9 ± 3.4 mm vs 26.6 ± 3.2 mm , P < .0001 ) was longer , but achievement of bidirectional block was higher ( 68.0 % vs 32.0 % , P = .0001 ) than in LLMI ablation . Mean duration of LAAW and LLMI ablations was 19.3 ± 2.9 minutes and 18.2 ± 3.7 minutes , respectively ( P = .086 ) . ( 3 ) During follow-up of 23.3 ± 7.4 months , the recurrence rate of AF after LAAW ablation ( 26.0 % ) was significantly lower than that of LLMI ablation ( 41.0 % , P = .021 ) after a single procedure . CONCLUSION The voltage map is useful for guiding linear ablation in persistent AF patients . LAAW is the most frequent low-voltage area around the mitral annulus , and linear ablation along LAAW results in a better clinical outcome with a higher rate of bidirectional conduction block compared to LLMI ablation Background —Electric isolation of the pulmonary veins and posterior left atrium with a single ring of radiofrequency lesions ( single-ring isolation [ SRI ] ) may result in fewer atrial fibrillation ( AF ) recurrences than wide antral pulmonary vein isolation ( wide antral isolation [ WAI ] ) by abolishing extravenous AF triggers . The effect of mitral isthmus line ( MIL ) ablation on outcomes after SRI has not previously been assessed . Methods and Results —We r and omly assigned 220 consecutive patients ( 58±10 years old ; 82 % men ) with highly symptomatic AF ( 61 % paroxysmal , 39 % persistent/longst and ing persistent ) to undergo either SRI or WAI .  Half of each cohort was also r and omly allocated to have left lateral MIL ablation ( 2 × 2 factorial study design ) . Patients were followed clinical ly and with 7-day Holter studies for arrhythmia recurrences . The primary end points were recurrence of AF and organized atrial tachyarrhythmias . AF-free survival at 2 years was better after SRI ( 74 % [ 95 % CI , 65%–82 % ] ) than WAI ( 61 % [ 51%–70 % ] ; P=0.031 ) . Organized atrial tachyarrhythmia – free survival was similar after SRI and WAI ( 67 % [ 57%–75 % ] ersus 64 % [ 54%–72 % ] , respectively , at 2 years ; P=0.988 ) . MIL ablation result ed in better 2-year organized atrial tachyarrhythmia – free survival ( 71 % [ 62%–79 % ] versus 60 % [ 50%–69 % ] ; P=0.07 ) , which approached statistical significance . Survival free of any atrial arrhythmia after one procedure was not significantly affected by isolation technique or MIL ablation . Conclusions —SRI result ed in fewer AF recurrences compared with WAI on long-term follow-up but did not reduce the recurrence of all atrial arrhythmias . MIL ablation may reduce organized atrial tachyarrhythmia recurrences . Clinical Trial Registration —http://www.anzctr.org.au ; ACTRN12606000467538 OBJECTIVES This study sought to compare catheter ablation with rate control for persistent atrial fibrillation ( AF ) in heart failure ( HF ) . BACKGROUND The optimal therapy for AF in HF is unclear . Drug-based rhythm control has not proved clinical ly beneficial . Catheter ablation improves cardiac function in patients with HF , but impact on physiological performance has not been formally evaluated in a r and omized trial . METHODS In a r and omized , open-label , blinded-endpoint clinical trial , adults with symptomatic HF , radionuclide left ventricular ejection fraction ( EF ) ≤35 % , and persistent AF were assigned to undergo catheter ablation or rate control . Primary outcome was 12-month change in peak oxygen consumption . Secondary endpoints were quality of life , B-type natriuretic peptide , 6-min walk distance , and EF . Results were analyzed by intention-to-treat . RESULTS Fifty-two patients ( age 63 ± 9 years , EF 24 ± 8 % ) were r and omized , 26 each to ablation and rate control . At 12 months , 88 % of ablation patients maintained sinus rhythm ( single-procedure success 68 % ) . Under rate control , rate criteria were achieved in 96 % . The primary endpoint , peak oxygen consumption , significantly increased in the ablation arm compared with rate control ( difference + 3.07 ml/kg/min , 95 % confidence interval : 0.56 to 5.59 , p = 0.018 ) . The change was not evident at 3 months ( + 0.79 ml/kg/min , 95 % confidence interval : -1.01 to 2.60 , p = 0.38 ) . Ablation improved Minnesota score ( p = 0.019 ) and B-type natriuretic peptide ( p = 0.045 ) and showed nonsignificant trends toward improved 6-min walk distance ( p = 0.095 ) and EF ( p = 0.055 ) . CONCLUSIONS This first r and omized trial of ablation versus rate control to focus on objective exercise performance in AF and HF shows significant benefit from ablation , a strategy that also improves symptoms and neurohormonal status . The effects develop over 12 months , consistent with progressive amelioration of the HF syndrome . ( A R and omised Trial to Assess Catheter Ablation Versus Rate Control in the Management of Persistent Atrial Fibrillation in Chronic Heart Failure ; NCT00878384 ) AIMS In many laboratories , cooled-tip catheters have replaced 8 mm-tip catheters due to their theoretical advantage of achieving larger lesions and avoiding charring . However , direct comparisons between the catheters in the subset of atrial fibrillation ( AF ) ablation are scarce . The aim of this study was to compare the efficacy , safety , and lesion extension created by 8 mm-tip vs. cooled-tip catheter with different energy setting s for circumferential pulmonary vein ablation ( CPVA ) . METHODS AND RESULTS A series of 221 consecutive patients with symptomatic AF were included in the study . Circumferential pulmonary vein ablation was performed using an 8 mm-tip catheter ( 55 W , 50 degrees C ) in 90 patients ( Group 1 ) , a cooled-tip ( 30 W , 45 degrees C ) in 42 ( Group 2 ) , and a cooled-tip ( 40 W , 45 degrees C ) in 89 ( Group 3 ) . In a subgroup of 60 patients , troponin I ( TpnI ) , creatinine kinase , and myoglobin values were obtained before and at 12 and 24 h after ablation . At 1 year follow-up , the probability of being arrhythmia-free after a single procedure was 53 , 35 , and 55 % in patients from Groups 1 , 2 , and 3 , respectively . Ablation with a cooled-tip catheter at 30 W led to a higher recurrence rate ( P = 0.030 ) and was identified in Cox regression analysis as an independent predictor of AF recurrence ( HR , 1.713 ; 95 % CI , 1.02 - 2.90 ; P = 0.045 ) . There were no differences in intra-procedure complications ( 2.2 vs. 5.6 vs. 4.9 % , P = 0.542 ) . The myocardial lesion according to TpnI was smaller in Group 2 ( P = 0.02 ) . CONCLUSION The cooled-tip catheter at 30 W was less efficacious than both the 8 mm catheter and the cooled-tip with a 40 W power setting BACKGROUND Additional ablation of complex fractionated atrial electrograms ( CFAE ) after pulmonary vein isolation ( PVI ) has been shown to improve the success of ablation of persistent atrial fibrillation ( AF ) . However , extensive ablation is often necessary to eliminate all CFAE or to terminate AF . We assessed the usefulness of the administration of an antiarrhythmic drug ( AAD ) before CFAE ablation . METHODS AND RESULTS One-hundred and ten patients with persistent AF first underwent PVI , roof and floor linear ablation ( box isolation ) . One hundred patients who remained in AF after box isolation were then r and omized to either receive ( AAD group , n=50 ) or not receive ( no-AAD group , n=50 ) intravenous nifekalant ( 0.3mg/kg ) followed by a CFAE ablation . In the AAD group , nifekalant terminated AF in 19 ( 38 % ) patients and ablation of localized CFAE was performed in 31 patients who remained in AF after nifekalant , and terminated AF in 11 ( 35 % ) patients . In the no-AAD group , ablation of CFAE terminated AF in 13 ( 26 % ) patients . The AAD group had a significantly lesser number of radio frequency applications at CFAE sites ( 18 ± 12 versus 36 ± 10 , p<0.0001 ) and shorter procedure time ( 162 ± 34 versus 197 ± 29 min , p<0.0001 ) compared with the no-AAD group . However , there was no significant difference in success rate at 12 months after a single ablation procedure between the two groups ( AAD group , 74 % versus no-AAD group , 76 % ) . CONCLUSIONS An approach to ablation using nifekalant may be useful in localizing areas of CFAE , reducing the number of applications at CFAE sites and procedure time . Ablation of only CFAE localized with nifekalant may be sufficient for clinical outcome BACKGROUND The relationship between the applied techniques and clinical outcomes after radiofrequency ( RF ) ablation of atrial fibrillation ( AF ) remains unclear . We compared the results of ablation by RF delivered via a point-by-point versus catheter dragging technique for the treatment of AF . METHODS This study included 66 patients with drug-refractory AF who underwent circumferential pulmonary vein ( PV ) ablation .  A point-by-point technique was used in 35 ( 53 % ) patients ( Group I ) , and catheter dragging technique in the remaining 31 ( 47 % ) patients ( Group II ) . If AF persisted or remained inducible after the PV isolation , additional ablation of complex fractionated atrial electrograms and linear ablation were performed . RESULTS Significantly , fewer RF applications were delivered in Group II than in Group I. The total RF energy duration delivered was comparable between the two groups ( P = 0.55 ) . However , the total energy of RF deliveries was significantly greater in Group II than in Group I ( P = 0.02 ) . Despite a longer fluoroscopic exposure time ( P = 0.01 ) , the total procedural duration was significantly shorter in Group II than in Group I ( P = 0.005 ) . Within 3 months after a single ablation procedure , 24 patients ( 69 % ) in Group I versus 13 patients ( 42 % ) in Group II had ≥1 recurrence(s ) of atrial tachyarrhythmias ( P = 0.03 ) . A multivariate analysis showed that a point-by-point ablation was the only independent predictor of early atrial tachyarrhythmia recurrences . CONCLUSIONS The catheter dragging technique for ablation of AF was associated with a lower early recurrence rate of atrial tachyarrhythmias than the point-by-point technique BACKGROUND Persistent and long-st and ing persistent atrial fibrillation ( AF ) often requires extensive and /or repeat radiofrequency ( RF ) ablation procedures . OBJECTIVE The Tailored Treatment of Persistent Atrial Fibrillation ( TTOP-AF ) study assessed the effectiveness and safety of the phased RF system in a r and omized controlled comparison of medical therapy against phased RF ablation for the management of persistent and long-st and ing persistent AF . METHODS Patients who had failed at least 1 antiarrhythmic drug ( AAD ) were r and omized ( 2:1 ) to ablation management ( AM ) or medical management ( MM ) . AM patients were allowed up to 2 ablations . Index and retreatment procedures consisted of pulmonary vein isolation and ablation of complex fractionated atrial electrograms . MM patients received AAD changes and /or cardioversion . The primary end points of the TTOP-AF study included chronic effectiveness and safety at 6 months and acute safety within 7 days of ablation . RESULTS At 6 months , a greater proportion of AM patients achieved effectiveness off AAD ( 77 of 138 [ 55.8 % ] ) compared to MM patients ( 19 of 72 [ 26.4 % ] ) ( P < .0001 ) . Acutely , 92.8 % ( 128/138 ) of the procedures were successful while 12.3 % ( 17/138 ) experienced a serious procedure and /or device-related adverse event . The predefined acute safety end point was not met . The proportion of patients with chronic safety events did not differ significantly between groups . CONCLUSIONS Catheter ablation of persistent/long-st and ing persistent AF with the phased RF ablation system is effective with greater reduction of AF compared with MM . More intense anticoagulation strategies , careful attention to catheter placement relative to the pulmonary vein ostia , and elimination of electrode interaction are expected to reduce the risk of stroke , pulmonary vein stenosis , and asymptomatic cerebral emboli BACKGROUND Both segmental ostial and circumferential extraostial pulmonary vein ( PV ) isolation have been proven effective in the treatment of atrial fibrillation ( AF ) . However , the recurrence of AF and PV conduction after the 2 ablation strategies has never been compared in a r and omized study . METHODS A total of 100 consecutive patients ( age 56 + /- 10 ; 71 men ) with symptomatic AF ( paroxysmal , 51 ; persistent , 49 ) were r and omized to segmental ostial ( n = 54 ) or circumferential extraostial ( n = 46 ) PV isolation . A circular catheter positioned at the ostium of each target PV guided the ostial PV isolation . Extraostial PV isolation was performed by encircling the paired left and right PVs , respectively , guided by an electroanatomic mapping system . RESULTS A total of 84 % of the patients had recurrent AF after the first PV isolation procedure , showing 72 % with AF and 12 % with organized left atrial tachycardia . In patients undergoing reablation , all but 2 patients had recurrence of left atrium PV conduction ( > 95 % ) . During a mean follow-up of 12 months without antiarrhythmic medication , 57 % of patients who underwent extraostial PV isolation were free of arrhythmia symptoms compared with 31 % of patients who underwent ostial PV isolation ( P < .05 ) . This difference in success rate between the 2 ablation strategies was mainly seen in patients known with persistent AF ( 52 % and 15 % , respectively ; P = .02 ) as opposed to patients with paroxysmal AF ( 65 % and 46 % , respectively ; P = .26 ) . CONCLUSIONS Overall , the more proximal , extraostial PV isolation was found to be superior to ostial PV isolation , especially in patients known with persistent AF . A high recurrence rate of 84 % after a single complete PV isolation procedure was seen . At reablation , more than 95 % had recurrence of left atrium PV conduction regardless of the procedure used , supporting the idea that complete PV isolation seems essential to prevent arrhythmia recurrences INTRODUCTION Pulmonary vein ( PV ) isolation for atrial fibrillation ( AF ) can be performed using a segmental ostial or a circumferential extra-ostial approach . The relative merits and potential limitations of each approach are currently debated . Here we report our early experience with each of these approaches , including their relative efficacy and safety . METHODS AND RESULTS Forty patients with drug-refractory AF underwent segmental ostial PV isolation and were compared to 40 consecutive patients who underwent PV isolation using a circumferential extra-ostial approach . The latter approach described here is novel in two aspects : ( 1 ) the endpoint for ablation was PV isolation and not only delay in left atrial to PV conduction time , and ( 2 ) isolation of the right and left PVs was achieved by a single encirclement of ipsilateral veins . At follow-up , 60 % of the patients in the segmental group were free of AF compared to 75 % of the patients in the circumferential group . There was one thromboembolic cerebrovascular complication during the ablation procedure in each group . CONCLUSION PV isolation using a circumferential extra-ostial approach , where the ipsilateral PVs are isolated together by one encircling line of block using electroanatomic mapping , is a technically feasible procedure . This approach is at least as effective and safe as the more established segmental ostial approach for AF ablation AIMS Ablation of complex fractionated atrial electrograms ( CFAEs ) is a new approach for the treatment of atrial fibrillation ( AF ) . The purpose of the study was to assess the efficacy of CFAE ablation as a st and -alone strategy in patients with persistent AF and to compare it with a combined approach of CFAE ablation and pulmonary vein isolation ( PVI ) . METHODS AND RESULTS The study included 77 consecutive patients with persistent AF who underwent radiofrequency ( RF ) ablation of CFAE as a sole ablation procedure ( CFAE group , n = 23 patients ) or a combined approach of CFAE ablation and PVI ( CFAE plus PVI group , n = 54 patients ) . Procedures were guided by three-dimensional mapping systems . After the procedure , AF recurrences were evaluated with 7-day Holter recordings at 1 , 3 , and 6 months and every 6 months thereafter . Treatment failure was defined as > or=1 AF episode lasting > 30 s on Holter recordings during follow-up . After a mean follow-up time of 13 + /- 10 months , 2 of 23 patients ( 9 % ) with CFAE ablation and 22 of 54 patients ( 41 % ) with CFAE plus PVI were in sinus rhythm after a single ablation procedure without anti-arrhythmic medication ( P = 0.008 ) . CONCLUSION Ablation of CFAE as a st and -alone ablation strategy seems insufficient for the treatment of patients with persistent AF . Pulmonary vein isolation plus CFAE ablation significantly increases the mid-term success rate
target: Where data were available , the relative benefits seen held true both after a single or multiple procedure(s ) .
  For patients with persistent atrial fibrillation , CA achieves significantly greater freedom from recurrent atrial fibrillation compared with medical therapy .
background: BACKGROUND Catheter ablation ( CA ) is commonly performed for persistent atrial fibrillation , but few high- quality r and omized controlled trials ( RCTs ) exist , leading to funding restrictions being proposed in several countries .
  We performed a r and om-effects meta- analysis of RCTs and non- RCTs to assess the efficacy of CA for persistent atrial fibrillation .