Advancing Catheter Ablation Strategies for Persistent Atrial Fibrillation: Insights from Two Clinical Trials

 Two Trials Provide Insights Into Catheter Ablation Options for Persistent AF

There remains a need to identify patients who will benefit from adjunctive techniques on top of pulmonary vein isolation (PVI).

For patients undergoing catheter ablation for persistent atrial fibrillation (AF), both cryoballoon and radiofrequency catheters are effective in achieving PVI.

The addition of linear ablation and alcohol ablation of the vein of Marshall may offer some benefits over PVI alone.

The CRRF-PeAF and PROMPT-AF trials provide important insights into improving treatment outcomes for persistent AF.

These trials were presented at the American Heart Association 2024 Scientific Sessions in Chicago, IL.

Experts consider the trials complementary steps toward advancing knowledge about persistent AF treatment.

Neither trial provided game-changing results but offered valuable guidance for clinicians.

Both cryoballoon and radiofrequency technologies are reasonable options if PVI is the goal.

The vein of Marshall ablation still has a role and may benefit certain patients.

A major challenge in the field is the lack of mechanistic understanding of persistent AF.

Efficacy of adjuncts to PVI likely varies depending on underlying factors causing persistent AF.

Cryoballoon and radiofrequency ablation remain the two primary methods for catheter ablation in persistent AF.

Multiple studies confirm similar outcomes for both energy sources when used for PVI.

Differences in AF recurrence patterns may arise from variations in reverse remodeling by energy source.

The CRRF-PeAF trial randomized 500 patients with persistent AF to cryoballoon or radiofrequency ablation.

Results showed successful PVI in all cases with shorter procedures for cryoballoon ablation.

Radiofrequency ablation was associated with greater left atrial reverse remodeling compared to cryoballoon ablation.

Both technologies produced similar clinical outcomes, including low complication rates.

Adding linear ablation plus alcohol ablation of the vein of Marshall was studied in the PROMPT-AF trial.

This adjunctive approach improved arrhythmia recurrence rates compared to PVI alone.

However, the additional ablations resulted in longer procedures and more complications.

No differences were observed in AF burden or quality of life between the two trial arms.

Experts question whether the benefits of alcohol ablation outweigh the added procedural complexity.

Take-Home Points

1. Cryoballoon and radiofrequency ablation are both effective options for PVI in persistent AF.
2. Adjunctive techniques, such as alcohol ablation, may improve outcomes for specific patients.
3. Mechanistic understanding of persistent AF is crucial for personalizing treatments.
4. Procedural duration, complications, and clinical relevance should guide decisions on adjunctive techniques.
5. Advancing AF treatment requires further trials to refine patient selection and optimize outcomes.