Effectiveness of stratified anatomical ablation (“BCXL”) for persistent atrial fibrillation: a retrospective cohort study

Radiofrequency ablation is the cornerstone treatment for persistent atrial fibrillation (AF); however, outcomes of pulmonary vein isolation (PVI) alone remain unsatisfactory. We aimed to assess a personalized stratified anatomical ablation strategy for persistent AF by comparing the effectiveness of BCXL (BC: extensive encircling PVI [EEPVI]; XL: stratified linear ablation based on left atrial substrate) with that of PVI. We retrospectively analyzed data from patients with persistent AF undergoing radiofrequency ablation at Xinqiao Hospital between 2017 and 2021. Patients were stratified into BCXL and PVI groups. The follow-up period was 24 months. The primary endpoint was the documented recurrence of atrial arrhythmia lasting ≥ 30 s after a 3-month blanking period. The study included 244 patients (BCXL group, n = 159; PVI group, n = 85). The ablation success rate at 24 months was significantly higher in the BCXL group than in the PVI group (80.4% vs. 63.8%, p = 0.006). Specifically, intermediate- to high-risk patients (CAAP-AF score > 5) in the BCXL group achieved a higher success rate than those in the PVI group (76.8% vs. 59.6%, p = 0.032). After adjusting for confounding factors (CAAP-AF score, left atrial low-voltage zone, age, sex, and body mass index), stratified anatomical ablation remained an independent predictor of ablation success (OR: 3.513; 95% CI: 1.725–7.154; p = 0.001). A personalized stratified anatomical ablation strategy improves radiofrequency ablation outcomes, particularly in patients with intermediate- to high-risk AF.