Pulmonary Vein Antrum Isolation (PVAI) Plus Scar Homogenization and Non-PV Triggers Ensure Long-term Recurrence-free Survival in Non-paroxysmal Atrial Fibrillation

Back ground: Pulmonary vein antrum isolation (PVAI) as a lone procedure, is known to have
limited success rate in terms of long-term recurrence-free survival in non-paroxysmal atrial
fibrillation (NPAF) and additional ablations isolating extra-PV triggers seem to improve the
outcome (1). The extra-PV triggers include triggers from other sites such as left atrial
posterior wall, superior vena cava, interatrial septum, crista terminalis, left atrial
appendage and coronary sinus (1, 2). These are known to be independent predictors of late AF
recurrence following catheter ablation (3, 4, and 5). Earlier studies have demonstrated
better ablation outcome in NPAF when non-PV triggers sites were isolated along with PVAI (5,
6). Moreover, Verma et al had reported high (57%) recurrence rate post-index procedure in AF
patients with pre-existent scar (7). However, published data are conflicting regarding the
benefits of additional substrate guided ablation (scar homogenization) compared to
conventional PVAI alone strategy (8). Also, limited data is available showing a comparison of
the lasting efficacy of the above three procedures when used in different combinations.

Hypothesis: The combined ablation strategy including PVAI, scar homogenization and ablation
of extra-PV triggers has the highest likelihood of maintaining long-term sinus rhythm in
patients with NPAF.

Inclusion Criteria:

1. Age ≥ 18 years

2. Patients undergoing first catheter ablation for drug-refractory Persistent (PerAF) or
long-standing persistent AF (LSPAF)

3. Ability to understand and provide signed informed consent

Exclusion Criteria:

1. Previous catheter ablation or MAZE procedure in left atrium

2. Reversible causes of atrial arrhythmia such as hyperthyroidism, sarcoidosis, pulmonary
embolism etc