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Linear ablation combined with ethanol infusion of the EIVOM provided additional benefit in rhythm outcomes in patients with persistent AF.

Among patients with persistent atrial fibrillation (AF), linear ablation combined with ethanol infusion of the vein of Marshall (EIVOM) provided additional benefit in rhythm outcomes, according to the PROMPT-AF trial published in JAMA.

“Although the latest expert consensus indicated that EIVOM may be reasonable for persistent AF ablation, it is still an area of uncertainty,” wrote Caihua Sang, MD, and colleagues. “The PROMPT-AF trial is the first randomized study demonstrating that a linear ablation strategy including EIVOM in addition to PVI [pulmonary vein isolation] significantly reduced atrial arrhythmia recurrence compared with PVI alone.”

PROMPT-AF was a randomized study conducted across 12 hospitals in China. They enrolled 498 patients aged 18 to 80 years, with AF persisting for more than 3 months, undergoing first-time AF ablation. Patients were randomly assigned in a 1:1 ratio to ablation consisting of PVI or PVI plus EIVOM and linear ablation. Patients in the intervention group first underwent EIVOM, then PVI and linear ablation at the left atrial roof, mitral isthmus, and cavotricuspid isthmus.

The primary analysis included 495 patients (72.9% men; mean age, 61.1 years). The primary endpoint was freedom from any documented atrial arrhythmia lasting 30 seconds or more, without antiarrhythmic drugs, within 12 months.

After 12 months, 70.7% of patients in the PVI plus EIVOM and linear ablation group achieved the primary endpoint versus 61.5% in the PVI group (HR, 0.73; 95% CI, 0.54-0.99; P=0.045). This finding remained consistent across all prespecified subgroups.

The secondary endpoints compared between both groups did not demonstrate significant results; however, many of these outcomes favored the intervention group. Freedom from any atrial arrhythmia recurrence, with or without antiarrhythmic drugs, was observed in 73.2% of patients in the intervention group compared with 64.7% of patients in the PVI alone group (HR, 0.74; 95% CI, 0.53-1.01). Additionally, 13.8% of patients in the intervention group compared with 17.3% of patients in the PVI alone group had documented atrial flutter or atrial tachycardia (HR, 0.79; 95% CI, 0.51-1.24).

They acknowledged that the study only included patients with AF longer than 3 months. The findings may not be generalizable to patients with shorter episodes of persistent AF.