Does Additional Linear Ablation after Circumferential Pulmonary Vein Isolation Improve Clinical Outcome in Patients with Paroxysmal Atrial Fibrillation? Prospective Randomized Study

Background: Circumferential pulmonary vein isolation (CPVI) has been considered as the cornerstone for radiofrequency Catheter ablation (RFCA) of atrial fibrillation (AF). However, it is unclear whether linear ablation in addition to CPVI improves clinical outcome. Methods: This study enrolled 156 patients (male 76.3%, 55.8±11.5 years old) who underwent RFCA for paroxysmal AF (PAF) as a prospective randomized study. We compared CPVI (n=52), CPVI+Roof line (CPVI+RL; n=52), and CPVI+RL+posterior inferior line (CPVI+PostBox; n=52) in terms of procedure time, ablation time, and clinical outcome. Results: 1. CPVI group showed shorter total procedure time (180.4± 39.5 min vs. 189.6±29.0 min, 201.7±51.7 min, respectively; p=0.035) and ablation time (4085.5±1384.1 sec vs. 5253.5±1010.9 sec, 5495.0 ±1316.0 sec, respectively; p<0.001) than CPVI+RL and CPVI+PostBox groups. 2. During 15.6±5.0 month follow-up, the recurrence rates three months after RFCA were 11.5% in CPVI, 21.2% in CPVI+RL, and 19.2% in CPVI+PostBox (p=0.440). 3. The achievement rate of bidirectional block was 100.0% in CPVI, 90.4% in CPVI+RL, and 59.6% in CPVI+PostBox. The clinical recurrence rates with or without achieving bidirectional block were not significantly different from each other (p=0.412). Conclusion: In patients with PAF, linear ablations in addition to CPVI did not improve clinical outcome, regardless of bidirectional block achievement, while it prolonged the total procedure and ablation time.