Pulmonary vein isolation plus left atrial posterior wall isolation and additional nonpulmonary vein trigger ablation using high‐dose isoproterenol for long‐standing persistent atrial fibrillation

BACKGROUND: Little evidence exists regarding the endpoint and optimum approach to catheter ablation for long‐standing persistent atrial fibrillation (LSPAF). We examined the efficacy of pulmonary vein isolation (PVI) plus left atrium posterior wall isolation (PWI) and additional non‐PV trigger ablation using high‐dose isoproterenol for LSPAF. METHODS: One‐hundred and fifty‐five patients (median AF duration, 36 months) underwent catheter ablation for LSPAF; After PVI plus PWI, they underwent provocation of non‐PV triggers by high‐dose isoproterenol and were divided into 3 groups based on the results: group A, PVI plus PWI alone, without induced non‐PV triggers (single procedure: 105 patients, multiple procedures: 90 patients); group B, mappable non‐PV triggers demonstrated and ablated (single procedure: 41 patients, multiple procedures: 45 patients); group C, if non‐PV triggers were unmappable or could not be induced in repeated procedures, adjunctive complex fractionated atrial electrogram ablation was performed (single procedure: 9 patients, multiple procedures: 20 patients). RESULTS: The Kaplan‐Meier estimate of the 1‐year freedom from atrial tachyarrhythmias without antiarrhythmic drugs was 65% in all patients, (73%, 56%, and 11% in groups A, B, and C, respectively) after a single procedure, which improved to 86% in all patients (93%, 86%, and 53% in groups A, B, and C, respectively) after multiple procedures. CONCLUSION: Even for LSPAF, in approximately 60% of patients, non‐PV triggers were not elicited, and PVI plus PWI alone achieved good outcomes. Although the inducibility of non‐PV triggers was associated with recurrence of atrial tachyarrhythmias, additional non‐PV trigger ablation may improve the outcome after multiple procedures.