Author + information
- Amir A. Schricker, MD, MS∗ (, )
- David E. Krummen, MD and
- Jonathan C. Hsu, MD, MAS
- ↵∗Division of Cardiovascular Medicine, Sulpizio Cardiovascular Center, 9444 Medical Center Drive, #7411, La Jolla, California 92037
We read with great interest the results of CHASE-AF (CatHeter Ablation of perSistEnt Atrial Fibrillation) by Vogler et al. (1), who reported that in patients with persistent atrial fibrillation (AF), a strategy aimed at defragmenting the atria via pulmonary vein isolation (PVI), complex fractionated atrial electrograms ablation, and linear ablation resulted in similar arrhythmia-free outcomes compared to a PVI-only strategy. The authors should be commended for rigorously conducting this important study that attempts to address the unanswered question of what to ablate beyond the pulmonary veins in AF patients.
Particularly remarkable are the 25% of study patients (52 of 205) in whom AF terminated acutely with PVI only, which is higher than previously published rates of 8% to 16% (2). The authors provide no additional information about these patients either in terms of differences in baseline characteristics or outcomes. These patients may represent an interesting population due to the mechanism by which their AF terminated, based on previous reports that coincidental elimination (e.g., via circumferential PVI) of rotors and localized AF-sustaining mechanisms may explain termination (3). Specifically, it would be informative to know whether AF terminated prior to isolation of the pulmonary vein (PV) (suggesting coincidental ablation of a localized source) or at the completion of PV isolation (suggesting PV-dependent AF).
The resounding message of CHASE-AF and similar studies is that more is not better with respect to AF ablation. Despite these elegant studies, electrophysiologists continue to seek guidance over what to target in 2 important AF patient populations: persistent AF and recurrent AF. Because recent published data shows that established ablation strategies including complex fractionated atrial electrograms ablation and linear lesions serve primarily to elevate complication risk without improving outcomes, it is incumbent upon future studies to evaluate in randomized fashion ablation strategies that evaluate alternative lesion sets versus those that target AF-sustaining mechanisms in these challenging patient subgroups.
Please note: Dr. Krummen has received grant support from NIH and UCSD Clinical Translation Research Institute; has consulted for Topera (terminated >14 months ago); and has received EP fellowship support from Biotronik, Biosense-Webster, Boston Scientific, Medtronic, and St. Jude.
Dr. Hsu has received honoraria from St. Jude Medical, Medtronic, and Biotronik; and has served on the advisory board for Janssen Pharmaceuticals and Bristol-Myers Squibb. Dr. Schricker has reported that he has no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation
- Vogler J.,
- Willems S.,
- Sultan A.,
- et al.
- Narayan S.M.,
- Krummen D.E.,
- Clopton P.,
- Shivkumar K.,
- Miller J.M.