Outcomes of long-standing persistent atrial fibrillation ablation: A systematic review

BackgroundAblation of long-standing persistent atrial fibrillation (AF) is highly variable, with differing techniques and outcomes.ObjectiveThe purpose of this study was to undertake a systematic review of the literature with regard to the impact of ablation technique on the outcomes of long-standing persistent AF ablation.MethodsA systematic search of the contemporary English scientific literature (from January 1, 1990 to June 1, 2009) in the PubMed database identified 32 studies on persistent/long-standing persistent or long-standing persistent AF ablation (including four randomized controlled trials). Data on single-procedure, drug-free success, multiple procedure success, and pharmaceutically assisted success at longest follow-up were collated.ResultsFour studies performed pulmonary vein isolation alone (21%–22% success). Four studies performed pulmonary vein antrum ablation with isolation (PVAI; n = 2; 38%–40% success) or without confirmed isolation (PVA; n = 2; 37%–56% success). Ten studies performed linear ablation in addition to PVA (n = 5; 11%–74% success) or PVAI (n = 5; 38%–57% success). Three studies performed posterior wall box isolation (n = 3; 44%–50% success). Five studies performed complex fractionated atrial electrogram ablation (n = 5; 24%–63% success). Six studies performed complex fractionated atrial electrogram ablation as an adjunct to PVA (n = 2; 50%–51% success), PVAI (n = 3; 36%–61% success), or PVAI and linear (n = 1; 68% success) ablation. Five studies performed the stepwise ablation approach (38%–62% success).ConclusionThe variation in success within and between techniques suggests that the optimal ablation technique for long-standing persistent AF is unclear. Nevertheless, long-standing persistent AF can be effectively treated with a composite of extensive index catheter ablation, repeat procedures, and/or pharmaceuticals.