Work

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

Year: 2026

Type: article

Abstract: 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.

Source: Heart Rhythm O2

DOI: 10.1016/j.hroo.2026.03.029