Hybrid Therapy of Class III Antiarrhythmic Drugs and Extensive Encircling Pulmonary Vein Isolation in Patient with Drug Resistant Very Long-Lasting Atrial Fibrillation

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Extensive encircling pulmonary vein isolation (EEPVI) and Class III anti-arrhythmic drugs (C3D) are established as a therapeutic option for paroxysmal atrial fibrillation (Afib). However, very long-lasting Afib (more than 1 year) is still difficult to manage. The purpose of this study is to evaluate the effectiveness of combination therapy of EEPVI and C3D in this patient group. One hundred fifteen patients (mean 57.7 y.o.) with mean Afib duration of 4.4 years were studied. Mean diameter of the left atrium (LA) was 43.8 mm. Before EEPVI multiple (1.6±1.2) anti-arrhythmic drugs including C3D in 107/115 patients were ineffective to restore sinus rhythm. In the first procedure EEPVI and cavotricuspid isthmus ablation was performed. In case of Afib recurrence C3D were prescribed and re-PV isolation with substrate modification (linear ablation in LA and ablation targeting CFAE) was performed. With 1.2 procedures Afib did not recur in 95 out of 115 patients (82%) during follow-up period of 20.4 months. 44 of 115 patients were drug free and the remainders were taking C3D (bepridil: mean 100 mg in 57 patients and amiodarone in 9 patients). LA volume index measured by echocardiogram was changed from 44.3±18.2 to 37.5±11.5 ml/m<SUP>2</SUP> through procedures (p<0.05). Hybrid therapy of class III antiarrhythmic drugs and EEPVI is effective to restore sinus rhythm and to reverse LA remodeling even in patients with very long-lasting atrial fibrillation.