Diffuse Posterior Wall Isolation and Durable Pulmonary Vein Isolation Persistence

A study was conducted to assess clinical outcomes for diffuse posterior wall isolation and investigate the durability of PVI among patients receiving repeat ablations.

A high rate of pulmonary vein isolation (PVI) durability is maintained in most patients receiving PVI with diffuse posterior wall isolation, according to results of a study published in the Journal of Cardiovascular Electrophysiology.

This was a retrospective analysis of prospectively collected data between 2017 and 2019 among patients receiving atrial fibrillation (AF) ablation at Vanderbilt University Medical Center. All patients (N=137) had diffuse posterior wall ablation in addition to PVI and received AF ablation using a 3.5-mm THERMOCOOL SMART-TOUCH contact force-sensing ablation catheter. Clinical outcomes through 2020 were evaluated.

The patients are aged mean 67±9 years, 65.0% are men, 96.4% are White, 79.6% have persistent AF, CHA2DS2-VASc score is 3.1±1.7, 78.1% have hypertension, 34.3% have left ventricular ejection fraction of less than 50%, and 41.6% have an additional cavotricuspid isthmus ablation.

Posterior wall isolation that achieved elimination of all posterior wall electrograms was highly successful (97.8%). The 3 incomplete procedures are due to esophageal temperature rise and a procedure-related tamponade event. No stroke, transient ischemic accident, phrenic nerve injury, odynophagia, or atrio-esophageal fistula events were observed.

Following PVI with diffuse posterior wall isolation, 3-month or longer of follow-up data is available for 126 patients. Over a median follow-up of 14 months, 30.2% of patients have an AF (n=22) or atrial flutter (AFL; n=13) recurrence. The recurrence events occur more often among older patients (P =.001), with higher CHA2DS2-VASc scores (P =.04), and those using antiarrhythmic drugs (P =.034).

The patients who require repeat ablation following PVI with diffuse posterior wall isolation (n=18) are more likely to have congestive heart failure (50.0% vs 8.9%; P <.001), fewer have pulmonary vein reconnection (11.1% vs 77.8%; P<.001), they have larger left atrial diameters (median, 46 vs 38 mm; P =.001), more have atrial tachycardia/AFL recurrence (72.2% vs 28.9%; P =.002), fewer have AF recurrence (44.4% vs 88.9%; P =.002), and more have persistent AF at index procedure (72.2% vs 42.2%; P =.05) compared with patients who require repeat ablation following PVI alone (n=45), respectively.

Among 18 patients who received repeat ablation following PVI with diffuse posterior wall isolation, 7 have complete durable posterior wall isolation and the remaining 11 have regional posterior wall electrical recovery. For the patients without durable posterior wall isolation, 9 have no electrical conduction.

The patients with durable isolation and electrical recovery differed significantly in left atrial diameter (median, 41 vs 51 mm; P =.02).

This study may have included selection bias, as the decision to perform PVI with diffuse posterior wall isolation was left to the physician’s discretion.

“Diffuse posterior wall ablation with a low‐flow, medium‐power, short‐duration protocol is safe, feasible, and efficacious with a favorable rate of maintaining sinus rhythm after ablation,” the study authors wrote. “Among patients undergoing repeat ablation, durable pulmonary vein isolation persisted in nearly 90% of patients after PVI plus [posterior wall isolation].”


Li DL, El-Harasis M, Montgomery JA, et al. Durable pulmonary vein isolation with diffuse posterior left atrial ablation using low‐flow, median power, short‐duration strategy. J Cardiovasc Electrophysiol. Published online May 22, 2022. doi:10.1111/jce.15550