Importance of non-pulmonary vein triggers ablation to achieve long-term freedom from paroxysmal atrial fibrillation in patients with low ejection fraction

Background Whether ablation of non-pulmonary vein (PV) triggers after pulmonary vein antrum isolation (PVAI) improves the long-term procedure outcome in patients with paroxysmal atrial fibrillation (PAF) and left ventricular systolic dysfunction is unknown. Objective We sought to evaluate whether a more extensive ablation procedure improves outcomes at follow-up. Methods Consecutive patients with PAF refractory to antiarrhythmic drugs presenting for PVAI were prospectively studied. Patients were categorized into 2 groups: patients with left ventricular ejection fraction (LVEF) ≤35% (group I; n = 175) and patients with LVEF ≥50% (group II; n = 545). Patients in group I were further divided according to whether additional ablation of non-PV triggers was performed (group IA; n = 88) or not (group IB; n = 87). Long-term ablation success off antiarrhythmic drugs after a single procedure was analyzed. Results Patients in group I had more non-PV triggers than did patients in group II (69.1% vs 26.6%; P <.001). During a follow-up of 15.8 ± 4.7 months, fewer patients in group I remained free from recurrences than those in group II (53.7% vs 81.7%; P <.001). Long-term ablation success was higher in group IA than in group IB (75.0% vs 32.2%; P <.001) and similar to that in group II (75.0% vs 81.7%; P =.44). In multivariate analysis, LVEF ≤35% (hazard ratio 1.68; P =.003) and non-PV triggers (hazard ratio 3.12; P <.001) were independent predictors of recurrences. Conclusion In patients with PAF and left ventricular systolic dysfunction, ablation of non-PV triggers in addition to PVAI significantly improves their long-term procedure outcome.