Targeting non-pulmonary vein triggers in persistent atrial fibrillation: Results from a prospective, multicentre, observational registry

Domenico G. Della Rocca, Luigi Di Biase, Sanghamitra Mohanty, Chintan Trivedi, Carola Gianni, Jorge Romero, Nicola Tarantino, Michele Magnocavallo, Mohamed Bassiouny, Veronica N. Natale, Angel Quintero Mayedo, Bryan Macdonald, Carlo Lavalle, Ghulam Murtaza, Krishna Akella, Giovanni B. Forleo, Amin Al-Ahmad, John David Burkhardt, Gerald Joseph Gallinghouse, Javier E. SanchezRodney P. Horton, Juan F. Viles-Gonzalez, Dhanunjaya Lakkireddy, Andrea Natale

Research output: Contribution to journalArticlepeer-review

38 Scopus citations


Aims: We evaluated the efficacy of an ablation strategy empirically targeting pulmonary veins (PVs) and posterior wall (PW) and the prevalence and clinical impact of extrapulmonary trigger inducibility and ablation in a large cohort of patients with persistent atrial fibrillation (PerAF). Methods and Results: A total of 1803 PerAF patients were prospectively enrolled. All patients underwent pulmonary vein antrum isolation (PVAI) extended to the entire PW. A standardized protocol was performed to confirm persistent PVAI and elicit any triggers originating from non-PV sites. All non-PV triggers initiating sustained atrial tachyarrhythmias were ablated. Ablation of non-PV sites triggering non-sustained runs (<30 s) of atrial tachyarrhythmias or promoting frequent premature atrial complexes (≥10/min) was left to operator's discretion. Overall, 1319 (73.2%) patients had documented triggers from non-PV areas. After 17.4 ± 8.5 months of follow-up, the cumulative freedom from atrial tachyarrhythmias among patients without inducible non-PV triggers (n = 484) was 70.2%. Patients with ablation of induced non-PV triggers had a significantly higher arrhythmia control than those whose triggers were not ablated (67.9% vs. 39.4%, respectively; P < 0.001). After adjusting for clinically relevant variables, patients in whom non-PV triggers were documented but not ablated had an increased risk of arrhythmia relapse (hazard ratio: 2.39; 95% confidence interval: 2.01-2.83; P < 0.001). Conclusion: Pulmonary vein antrum isolation extended to the entire PW might provide acceptable long-term arrhythmia-free survival in PerAF patients without inducible non-PV triggers. In our population of PerAF patients, non-PV triggers could be elicited in ∼70% of PerAF patients and their elimination significantly improved outcomes.

Original languageEnglish (US)
Pages (from-to)1939-1949
Number of pages11
Issue number12
StatePublished - Dec 1 2021


  • Catheter ablation
  • Non-pulmonary vein triggers
  • Outcomes
  • Persistent atrial fibrillation
  • Pulmonary veins
  • Registry

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Physiology (medical)


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