Background: Catheter ablation has become the first line of therapy in patients with symptomatic, recurrent, drug-refractory atrial fibrillation. Circumferential pulmonary vein ablation is still the standard approach in these patients. However, the results are not very favourable and more complex ablation strategies are the subject of current controversy.

Therefore, we have evaluated the effect of an additional linear lesion at the roof of the left atrium on the long-term outcome.

Methods: A total of 260 patients (135 men, 125 women; mean age 70 years (SD ± 15 years)) with symptomatic persistent atrial fibrillation underwent a circumferential pulmonary vein ablation procedure in combination with an additional linear lesion at the roof of the left atrium (group A). After discharge, patients were scheduled for repeated visits at the arrhythmia clinic at 1, 3, 6, 12, 24, 36, 48, 60, 72, 84, 96, 102,  108 and 120 months after the ablation procedure. 

The long-term follow-up data was compared to 260 patients who underwent circumferential pulmonary vein ablation without an additional linear lesion at the roof of the left atrium (group B).

   
Results: The ablation procedure could be performed as planned in all patients.

    Sixty out of 260 patients (23.1 %) in group A and 61 out of 260 patients (23.5 %) in group B experienced an arrhythmia recurrence within the first 3 months after ablation requiring an electrical cardioversion. At 120-month follow-up, analysis of a 168-hour ECG recording revealed no evidence for an arrhythmia recurrence in    150/260 patients (57.7 %) in group A and in 126/260 patients (48.5 %) in group B. In 77/260 patients (29.6 %) in group A and 70/260 patients (26.9 %) in group B, only short episodes of paroxysmal atrial fibrillation were documented. In 33 patients (12.7 %) in group A, a recurrence of persistent atrial fibrillation (> 48 hours) was revealed by the long-term recordings (group B: 64 patients (24.6 %)). The lower arrhythmia recurrence rate in group A was partially due to a lower incidence of atypical atrial flutter after catheter ablation. The rate of repeat ablation procedures was significantly lower in group A than in group B. There were no major complications.

Conclusions: Catheter ablation of persistent atrial fibrillation comprising a circumferential pulmonary vein ablation and an additional linear lesion at the roof of the left atrium provides more favourable results than circumferential pulmonary vein ablation alone. The effect is more pronounced during long-term than during short-term follow-up.