Circumferential pulmonary vein ablation with additional linear ablation results in an increased incidence of left atrial flutter compared with segmental pulmonary vein isolation as an initial approach to ablation of paroxysmal atrial fibrillation.

BACKGROUND: There has been growing concern that linear ablation is associated with an increased risk of iatrogenic arrhythmias in patients undergoing ablation for atrial fibrillation (AF). Therefore, we compared circumferential pulmonary vein ablation plus left atrial linear ablation (CPVA+LALA) with segmental pulmonary vein isolation (PVI)in patients with paroxysmal AF.

METHODS AND RESULTS: Sixty-six consecutive patients with paroxysmal AF were prospectively randomly assigned to receive PVI versus CPVA+LALA (consisting of encircling lesions around the pulmonary veins), a roof line, and a mitral isthmus line with documentation of bidirectional mitral isthmus block. All patients were seen at 1, 3, 6, and every 12 months after ablation, with 14-day continuous ECG monitoring every 6 months. At 16.4+/-6.3 months after 1 ablation procedure, 19 patients (58%) remained free of atrial arrhythmias after PVI versus 17 patients (51%) after CPVA+LALA (P=0.62). After PVI, 14 patients had recurrent paroxysmal AF, whereas after CPVA+LALA, 8 patients had recurrent AF, 6 had atypical left atrial flutter (LAFL), and 2 had both AF and LAFL (P=0.32 between PVI versus CPVA+LALA for AF but P=0.002 for LAFL). Twenty-eight patients (85%) remained arrhythmia-free after 1.3+/-0.5 PVI procedures versus 28 patients (85%) after 1.4+/-0.6 CPVA+LALA procedures (P=NS). Fluoroscopy time was longer after CPVA+LALA versus PVI (91 versus 73 minutes, P=0.04).

CONCLUSIONS: As an initial ablation approach in patients with paroxysmal AF, more LAFL occurred after CPVA+LALA and fluoroscopy times were longer compared with segmental PVI.