Atrial fibrillation: time to personalise the ablation approach?


Take Home Messages
  • The variable success rate of pulmonary vein isolation (PVI) in the treatment of persistent atrial fibrillation (AF) has prompted the development of ablation strategies targeted outside the pulmonary veins.
  • The DECAAF II study examined the hypothesis that PVI+fibrosis guided ablation during the first procedure, would improve freedom from arrhythmia compared with PVI alone for persistent AF.
  • The study found no significant differences in atrial arrhythmia recurrence amongst patients treated with PVI+fibrosis guided ablation versus PVI alone.
  • This study presented an important negative finding and further supports the use of PVI alone as the first-line strategy in persistent AF patients.
  • Further studies are warranted to delineate the role of fibrosis-guided ablation in selected cases. Advances in computational modeling studies offer the potential to deliver personalised therapy for AF patients.

The importance of pulmonary vein ectopy in the initiation and maintenance of atrial fibrillation (AF) is well recognised (1) resulting in pulmonary vein isolation (PVI) forming a key component of AF ablation procedures. The success rates of PVI alone are variable, and it has been observed that persistent AF ablation success rates (40-70%) are lower than paroxysmal AF success rates (60-70%) (2). The variability in reported outcomes may reflect variation in definitions of success, intensity of monitoring and the impact of non-pulmonary vein triggers or substrates for AF. Numerous strategies comprising substrate ablation beyond PVI have been investigated with variable degrees of success (3) iterating the requirement for better, more targeted ablation approaches. This editorial discusses the Determinant of Successful Radiofrequency Catheter Ablation of Atrial Fibrillation (DECAAF) II trial which aimed to assess the impact of PVI plus MRI-guided atrial fibrosis ablation versus PVI alone in persistent AF.