Selective Ablation of Low Voltage and Electrogram Fractionation During Sinus Rhythm in Patients with Persistent Atrial Fibrillation (SOLVE-AF) – A Prospective Randomized Multicenter Trial

A. S. Jadidi (Luzern 16)¹, H. Taiyuan (Luzern)², B. Müller-Edenborn (Freiburg im Bresigau)³, A. Luik (Karlsruhe)⁴, M. Kuniss (Bad Nauheim)⁵, T. Neumann (Bad Nauheim)⁵, P. Sommer (Bad Oeynhausen)⁶, C. Meyer (Düsseldorf)⁷, A. Metzner (Hamburg)⁸, S. Rolf (Berlin)⁹, G. Hindricks (Berlin)¹⁰, D. Trenk (Bad Krozingen)¹¹, D. Westermann (Freiburg im Breisgau)¹², M. Eichenlaub (Bad Krozingen)¹³, H. Lehrmann (Bad Krozingen)¹⁴, T. Arentz (Bad Krozingen)^15
1Luzerner Kantonsspital Herzzentrum Luzern, Schweiz; ²Herzzentrum Luzern, Kantonsspital Luzern Rhythmologie Luzern, Schweiz; ³Uniklinik Freiburg Rhythmologie Freiburg im Bresigau, Deutschland; ⁴Städtisches Klinikum Karlsruhe gGmbH Med. IV, Schwerpunkt Kardiologie, Angiologie und Internistische Intensivmedizin Karlsruhe, Deutschland; ⁵Kerckhoff Klinik GmbH Abteilung für Kardiologie Bad Nauheim, Deutschland; ⁶Herz- und Diabeteszentrum NRW Klinik für Elektrophysiologie/ Rhythmologie Bad Oeynhausen, Deutschland; ⁷Evangelisches Krankenhaus Düsseldorf Klinik für Kardiologie Düsseldorf, Deutschland; ⁸Universitäres Herz- und Gefäßzentrum Hamburg Klinik für Kardiologie mit Schwerpunkt Elektrophysiologie Hamburg, Deutschland; ⁹DRK-Kliniken Berlin Westend Klinik für Innere Medizin Schwerpunkt Kardiologie Berlin, Deutschland; ¹⁰Charité - Universitätsmedizin Berlin CC11: Med. Klinik m. S. Kardiologie und Angiologie Berlin, Deutschland; ¹¹Universitäts-Herzzentrum Freiburg / Bad Krozingen Klinische Pharmakologie Bad Krozingen, Deutschland; ¹²Universitäts-Herzzentrum Freiburg - Bad Krozingen Innere Medizin III, Kardiologie und Angiologie Freiburg im Breisgau, Deutschland; ¹³Universitäts-Herzzentrum Freiburg / Bad Krozingen Klinik für Kardiologie und Angiologie Bad Krozingen, Deutschland; ¹⁴Universitäts-Herzzentrum Freiburg / Bad Krozingen Klinik für Kardiologie und Angiologie II Bad Krozingen, Deutschland; ¹⁵Universitäts-Herzzentrum Freiburg / Bad Krozingen Rhythmologie Bad Krozingen, Deutschland

Background: The optimal catheter ablation strategy for patients with persistent atrial fibrillation (AF) is unknown. We assess the impact of circumferential PVI (CPVI) plus additional ablation of low voltage and slow conduction sites (assessed as fractionation during sinus rhythm (SR)) on arrhythmia freedom rate at 12 months in a large cohort of persistent AF patients.

Methods: 231 patients with persistent AF undergoing de-novo catheter ablation for AF were prospectively included. Patients underwent LA high-density voltage and activation mapping in SR. Patients with presence of LA low voltage substrate (LVS) <0.5mV exceeding 4cm2 were randomized to “CPVI-only” or CPVI plus additional selective ablation of low voltage and fractionated electrograms recorded in SR (“CPVI-plus”). Patients without LVS were considered as “registry group (REG)” and underwent CPVI-only. Patients underwent 7-day Holter recordings at 3-, 6- and 12-months post-ablation. Arrhythmia recurrence was considered if a single episode of AF or AT/flutter lasting >30sec occurred after a blanking period of 3 months during a FU of 12 months post catheter ablation.

Results: Patients without relevant LVS (n=123) were younger than those with LVS (n=108, 63±9.0 vs. 71±7, p<0.001) and were more frequently male 81.3% vs. 50.5% (p<0.001). Arrhythmia freedom rate at 12-months was significantly lower in patients with relevant LVS undergoing “CPVI-only”, compared to those without LVS (REG) undergoing CPVI: 58.9% vs. 76.80%, p=0.012). Patients with relevant LVS undergoing “CPVI plus” had improved arrhythmia freedom rates at 12-months: “CPVI plus” vs. “CPVI-only”, 76.3% vs. 58.9%, p=0.040; “CPVI-plus” vs. REG: p=0.977). 12-months AF-recurrence rates were: 10.7% vs.  16.2% vs. 33.4% for “CPVI-plus” vs. REG vs. “CPVI-only”, respectively; p significant for “CPVI-plus” vs “CPVI-only” and REG vs. “CPVI-only”).

Conclusions: Sinus rhythm maintenance after CPVI-only is significantly reduced in persistent AF patients with relevant LVS, compared to those without. CPVI plus additional ablation of low voltage and electrogram fractionation during sinus rhythm completely restores arrhythmia freedom rates in patients with relevant LVS.