Additional linear ablation from the superior vena cava to right atrial septum after pulmonary vein isolation improves the clinical outcome in patients with paroxysmal atrial fibrillation: Prospective randomized study

Aims Although circumferential pulmonary vein isolation (CPVI) has been considered as the cornerstone for paroxysmal atrial fibrillation (PAF) ablation, there has been a substantial recurrence rate. We conducted a prospectively randomized study to evaluate whether additional linear ablation from the superior vena cava (SVC) to the right atrial (RA) septum (SVC-L) improves the clinical outcome. Methods and results This study enroled 200 patients with PAF (male 74.5%, 56.8±11.7 years old) randomly assigned to either the CPVI (n = 100) or CPVI + SVC-L (n = 100) groups. An RA isthmus ablation was performed in all patients. The CPVI + SVC-L group required a longer ablation procedure time (82.7±17.9 min) than the CPVI group (63.6±16.8 min, P < 0.001). The complication rates were 5% in CPVI + SVC-L group and 2% in CPVI group, respectively (P = 0.445). Two CPVI + SVC-L group patients had post-procedural sinus node dysfunction, which recovered within 24 h. During 12.2±5.3 months of follow-up, the recurrence rate was significantly lower in the CPVI + SVC-L group (6%) than the CPVI group (27%, P < 0.001). The post-procedural 3-month follow-up heart rate variability in the CPVI + SVC-L group showed a significantly greater reduction in the rMSSD (25.2±13.7 vs. 13.7±8.5 ms, P < 0.001), HF (10.2±7.1 vs. 5.5±5.8 ms2, P < 0.001), and LF/HF (1.6±0.5 vs. 0.9±0.3, P < 0.001) than in the CPVI group. Conclusion In spite of a longer procedure time and risk of transient sinus node dysfunction, an SVC-L in addition to CPVI improved the clinical outcome of catheter ablation, and was associated with post-procedural autonomic neural remodelling in patients with PAF.