Ablation of visually identified spatiotemporal dispersion plus pulmonary vein isolation in persistent atrial fibrillation

Abstract Aims Pulmonary vein isolation (PVI) provides limited efficacy in persistent atrial fibrillation (AF). We performed PVI plus ablation of areas with visually detected spatiotemporal dispersion (STD) in consecutive patients with persistent AF, and compared them with a 1:1 propensity score-matched cohort of patients treated with a PVI-only approach. Methods and results STD was visually identified using conventional high-density mapping catheters (IntellaMap ORION, PentaRay NAV, or Advisor HD Grid), without dedicated software. Areas with STD showing fractionated continuous electrograms (FCEs), if present, were ablated first, and other areas with STD were ablated in cases without AF conversion during ablation of FCEs. The right atrium was treated only in cases without AF conversion during left atrial ablation in which the AF cycle length was faster at the right atrium. Hundred patients were treated with each ablation strategy (PVI + STD or PVI-only) (63.9 ± 10.1 years, 28% females). Thirty-five patients from the PVI + STD group showed areas with FCEs, which were ablated first, achieving AF termination in nine patients. In the remaining 91 patients, 221 areas with STD were ablated. The right atrium was treated in 48 patients. Globally, AF conversion was achieved in 33 patients. The PVI + STD group showed lower atrial arrhythmia recurrences at 18-month follow-up (30% vs. 53%, P < 0.001) and after a median follow-up of 45 [26–66] months (44% vs. 71%, P < 0.001), and less progression to permanent AF (14% vs. 41%, P < 0.001). Conclusion Ablation of areas with visually identified STD, added to PVI, reduced atrial arrhythmia recurrences and decreased progression to permanent AF.