Rotor-guided tailor-made pulmonary vein isolation for persistent atrial fibrillation: Identification of the left atrial septum as a common arrhythmogenic substrate

Background In patients with persistent atrial fibrillation (PerAF), additional substrate modification beyond pulmonary vein isolation (PVI) is controversial, given limited durability and increased atrial tachycardias (ATs). ExTRa Mapping system is a new tool to clarify the real-time imaging of AF rotors. Objective We evaluated the efficacy of extended PVI that combines cryoballoon PVI with tailor-made radiofrequency (RF) ablation of PV antrum rotors identified by ExTRa Mapping. Methods Fifty-eight patients with PerAF underwent initial ablation using a tailored strategy: cryoballoon PVI followed by RF line extension to encompass adjacent AF rotors identified by ExTRa Mapping (Rotor-guided extended PVI group). Outcomes were compared with two contemporaneous control groups: (1) cryoballoon PVI alone (PVI-alone group, n=33), and (2) RF-based PVI plus posterior wall isolation (PWI) (PVI plus PWI group, n=43). The primary endpoint was freedom from AF/AT recurrence without antiarrhythmic drugs at 12 months. Results Baseline characteristics were comparable among groups. LA septal NPAs were observed in 70.7% of patients and were the most common location. Accordingly, in Rotor-guided extended PVI group, anterior extension from right PV (RPV) toward LA septal rotor was the most frequently applied strategy. At 12 months, freedom from AF/AT was significantly higher in Rotor-guided extended PVI group (89.7%) compared to PVI-alone group (63.6%) and PVI plus PWI group (65.1%) (log-rank P=0.004). In multivariable Cox analysis, the rotor-guided extended PVI strategy was independently associated with a lower risk of AF/AT recurrence. Conclusion Cryoballoon PVI combined with ExTRa Mapping-guided RF ablation targeting adjacent rotors improves arrhythmia outcomes without increasing ATs.