Comparison of Pulmonary Vein Ablation With or Without Left Atrial Posterior Wall Ablation for Persistent AF (PIVoTAL)

NCT03057548 | Completed Results

• 1 other identifier: PIVotal-01
• Study Type: interventional
• Target: 110
• Locations: 2 countries
• Sites: 2

Brief Summary

The purpose of this study it to learn whether pulmonary vein isolation (PVI) along with ablation of the posterior left atrial wall (PLAW) will reduce the likelihood of atrial fibrillation (AF) recurrence in patients with persistent or long-standing persistent AF one year after an ablation procedure in comparison to a PVI ablation procedure, alone. The investigator hypothesizes that the combination of PVI plus PLAW isolation will result in a reduction in recurrence of atrial arrhythmias at one year after ablation.

Conditions

Atrial Fibrillation Chronic; Persistent Atrial Fibrillation

Keywords

Atrial Fibrillation; Long-Standing Atrial Fibrillation; Posterior Left Atrial Wall Ablation

Outcome Measures

Primary Outcomes (1)

• 1-year Freedom From Recurrent Atrial Arrhythmias

  The results of 7-14 day ambulatory ECG monitoring and ECGs performed at 3, 6 and 12 months will be used to document freedom from recurrent atrial fibrillation at one year post-ablation.

  One year

Secondary Outcomes (1)

• Overall Complication Rate

  During follow-up, assessed for an estimated total of one year.

Study Arms (2)

Pulmonary Vein Isolation (PVI)

ACTIVE COMPARATOR

Cryoablation only of Pulmonary Veins or Radiofrequency ablation only of Pulmonary Veins Pulmonary Vein Isolation (PVI) alone.

Procedure: Cryo or Radiofrequency (RF) Ablation only of Pulmonary Veins

PVI & Posterior Left Atrial Ablation

EXPERIMENTAL

Cryoablation of Pulmonary Veins plus RF ablation of Posterior Left Atrial Wall or Radiofrequency ablation of Pulmonary Veins plus RF ablation of Posterior Left Atrial Wall PVI ablation plus ablation of the Posterior Left Atrial Wall (PLAW)

Procedure: Cryo or RF Ablation of Pulmonary Veins plus Ablation of the PLAW

Interventions

Cryo or Radiofrequency (RF) Ablation only of Pulmonary Veins PROCEDURE

Artic Front Advance Cardiac Cryoablation System used to ablate the Pulmonary Veins OR FDA Approved RF Ablation Catheter used to ablate the Pulmonary Veins. Ablation of the Pulmonary Veins alone

Also known as: Artic Front Advance Cardiac Cryoablation System, FDA Approved Radiofrequency Ablation Catheter

Pulmonary Vein Isolation (PVI)

Cryo or RF Ablation of Pulmonary Veins plus Ablation of the PLAW PROCEDURE

Cryoablation of the Pulmonary Veins plus RF Ablation of the PLAW OR RF Ablation of the Pulmonary Veins plus RF Ablation of the PLAW Ablation of the Pulmonary Veins plus RF ablation of the Posterior Left Atrial Wall (PLAW)

Also known as: Cryoablation of Pulmonary Veins plus RF Ablation of PLAW, RF Ablation of Pulmonary Veins plus RF Ablation of PLAW

PVI & Posterior Left Atrial Ablation

Eligibility Criteria

• Age: 18 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Adult (18-64), Older Adult (65+)

You may qualify if:

• Males and females with an age \>18 years undergoing a first-time catheter ablation of AF; prior ablation of a right atrial cardiac arrhythmia (i.e., typical right atrial flutter) is permitted
• All patients must understand the requirements of the study and be willing to comply with the post-study follow-up requirements
• Patients must be in AF on the day of the procedure

You may not qualify if:

• Any reversible cause of AF (post-operative, thyroid disorder, etc)
• Patients with cerebral ischemic events (stroke or transient ischemic attack), myocardial infarction or unstable angina in the previous 2 months
• Patients with any corrected or uncorrected congenital heart disease
• Patients with a history of hypertrophic cardiomyopathy
• Patients with cardiomyopathy and a left ventricular ejection fraction \<35%
• Congestive heart failure, class IV
• Women who are known to be pregnant or have had a positive β-Human Chorionic Gonadotropin (β-HCG) test 7 days prior to procedure
• Patients whose life expectancy is \<1 year
• History of left-sided left atrial ablation (catheter or surgically-based)
• Mental impairment precluding the patient from providing informed consent or completing appropriate follow-up

Sponsors & Collaborators

• Arash Aryana, MD: lead

Study Sites (2)

Mercy General Hospital and Dignity Health Heart and Vascular Institute

Sacramento, California, 95819, United States

Location

Heart Center, Japan Red Cross Yokohama-city Bay Hospital

Yokohama, Japan

Location

Related Publications (13)

• Haissaguerre M, Jais P, Shah DC, Takahashi A, Hocini M, Quiniou G, Garrigue S, Le Mouroux A, Le Metayer P, Clementy J. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med. 1998 Sep 3;339(10):659-66. doi: 10.1056/NEJM199809033391003.

  PMID: 9725923 BACKGROUND

• Brooks AG, Stiles MK, Laborderie J, Lau DH, Kuklik P, Shipp NJ, Hsu LF, Sanders P. Outcomes of long-standing persistent atrial fibrillation ablation: a systematic review. Heart Rhythm. 2010 Jun;7(6):835-46. doi: 10.1016/j.hrthm.2010.01.017. Epub 2010 Jan 22.

  PMID: 20206320 BACKGROUND

• Segerson NM, Daccarett M, Badger TJ, Shabaan A, Akoum N, Fish EN, Rao S, Burgon NS, Adjei-Poku Y, Kholmovski E, Vijayakumar S, DiBella EV, MacLeod RS, Marrouche NF. Magnetic resonance imaging-confirmed ablative debulking of the left atrial posterior wall and septum for treatment of persistent atrial fibrillation: rationale and initial experience. J Cardiovasc Electrophysiol. 2010 Feb;21(2):126-32. doi: 10.1111/j.1540-8167.2009.01611.x. Epub 2009 Oct 5.

  PMID: 19804549 BACKGROUND

• Cutler MJ, Johnson J, Abozguia K, Rowan S, Lewis W, Costantini O, Natale A, Ziv O. Impact of Voltage Mapping to Guide Whether to Perform Ablation of the Posterior Wall in Patients With Persistent Atrial Fibrillation. J Cardiovasc Electrophysiol. 2016 Jan;27(1):13-21. doi: 10.1111/jce.12830. Epub 2015 Oct 30.

  PMID: 26515166 BACKGROUND

• Elbatran AI, Anderson RH, Mori S, Saba MM. The rationale for isolation of the left atrial pulmonary venous component to control atrial fibrillation: A review article. Heart Rhythm. 2019 Sep;16(9):1392-1398. doi: 10.1016/j.hrthm.2019.03.012. Epub 2019 Mar 16.

  PMID: 30885736 BACKGROUND

• Corradi D, Callegari S, Maestri R, Ferrara D, Mangieri D, Alinovi R, Mozzoni P, Pinelli S, Goldoni M, Privitera YA, Bartoli V, Astorri E, Macchi E, Vaglio A, Benussi S, Alfieri O. Differential structural remodeling of the left-atrial posterior wall in patients affected by mitral regurgitation with or without persistent atrial fibrillation: a morphological and molecular study. J Cardiovasc Electrophysiol. 2012 Mar;23(3):271-9. doi: 10.1111/j.1540-8167.2011.02187.x. Epub 2011 Sep 28.

  PMID: 21954878 BACKGROUND

• Nagashima K, Okumura Y, Watanabe I, Nakahara S, Hori Y, Iso K, Watanabe R, Arai M, Wakamatsu Y, Kurokawa S, Mano H, Nakai T, Ohkubo K, Hirayama A. Hot Balloon Versus Cryoballoon Ablation for Atrial Fibrillation: Lesion Characteristics and Middle-Term Outcomes. Circ Arrhythm Electrophysiol. 2018 May;11(5):e005861. doi: 10.1161/CIRCEP.117.005861.

  PMID: 29700055 BACKGROUND

• Okumura Y, Watanabe I, Iso K, Takahashi K, Nagashima K, Sonoda K, Mano H, Yamaguchi N, Kogawa R, Watanabe R, Arai M, Ohkubo K, Kurokawa S, Nakai T, Hirayama A. Mechanistic Insights Into Durable Pulmonary Vein Isolation Achieved by Second-Generation Cryoballoon Ablation. J Atr Fibrillation. 2017 Apr 30;9(6):1538. doi: 10.4022/jafib.1538. eCollection 2017 Apr-May.

  PMID: 29250289 BACKGROUND

• Reddy VY, Sediva L, Petru J, Skoda J, Chovanec M, Chitovova Z, Di Stefano P, Rubin E, Dukkipati S, Neuzil P. Durability of Pulmonary Vein Isolation with Cryoballoon Ablation: Results from the Sustained PV Isolation with Arctic Front Advance (SUPIR) Study. J Cardiovasc Electrophysiol. 2015 May;26(5):493-500. doi: 10.1111/jce.12626. Epub 2015 Apr 15.

  PMID: 25644659 BACKGROUND

• Aryana A, Baker JH, Espinosa Ginic MA, Pujara DK, Bowers MR, O'Neill PG, Ellenbogen KA, Di Biase L, d'Avila A, Natale A. Posterior wall isolation using the cryoballoon in conjunction with pulmonary vein ablation is superior to pulmonary vein isolation alone in patients with persistent atrial fibrillation: A multicenter experience. Heart Rhythm. 2018 Aug;15(8):1121-1129. doi: 10.1016/j.hrthm.2018.05.014.

  PMID: 30060879 BACKGROUND

• Nishimura T, Yamauchi Y, Aoyagi H, Tsuchiya Y, Shigeta T, Nakamura R, Yamashita M, Asano M, Nakamura T, Suzuki H, Shimura T, Kurabayashi M, Keida T, Sasano T, Hirao K, Okishige K. The clinical impact of the left atrial posterior wall lesion formation by the cryoballoon application for persistent atrial fibrillation: Feasibility and clinical implications. J Cardiovasc Electrophysiol. 2019 Jun;30(6):805-814. doi: 10.1111/jce.13879. Epub 2019 Feb 23.

  PMID: 30767365 BACKGROUND

• Aryana A, Kenigsberg DN, Kowalski M, Koo CH, Lim HW, O'Neill PG, Bowers MR, Hokanson RB, Ellenbogen KA; Cryo-DOSING Investigators. Verification of a novel atrial fibrillation cryoablation dosing algorithm guided by time-to-pulmonary vein isolation: Results from the Cryo-DOSING Study (Cryoballoon-ablation DOSING Based on the Assessment of Time-to-Effect and Pulmonary Vein Isolation Guidance). Heart Rhythm. 2017 Sep;14(9):1319-1325. doi: 10.1016/j.hrthm.2017.06.020. Epub 2017 Jun 15.

  PMID: 28625929 BACKGROUND

• Markides V, Schilling RJ, Ho SY, Chow AW, Davies DW, Peters NS. Characterization of left atrial activation in the intact human heart. Circulation. 2003 Feb 11;107(5):733-9. doi: 10.1161/01.cir.0000048140.31785.02.

  PMID: 12578877 BACKGROUND

MeSH Terms

Conditions

Atrial Fibrillation

Condition Hierarchy (Ancestors)

Arrhythmias, Cardiac; Heart Diseases; Cardiovascular Diseases; Pathologic Processes; Pathological Conditions, Signs and Symptoms

Limitations and Caveats

Slight variations in ablation strategy/periprocedural management may have existed among operators. Baseline Left Atrial Posterior Wall low-voltage data were collected in AF at procedure start, which could have implications. Subclinical manifestations of complications (ex. esophageal ulcerations or asymptomatic PV stenosis) could not be excluded as diagnostic studies weren't performed in follow-up. Recurrent asymptomatic atrial arrhythmias could have occurred without detection during follow-up.

Results Point of Contact

• Title: Arash Aryana, MD, PhD
• Organization: SacEP Research

a_aryana@outlook.com

916-453-2684

Study Officials

• Arash Aryana, MD

  Mercy General Hospital and Dignity Health Heart and Vascular Institute

  PRINCIPAL INVESTIGATOR

Publication Agreements

• PI is Sponsor Employee: No
• Restrictive Agreement: No

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: DOUBLE
• Who Masked: PARTICIPANT, INVESTIGATOR
• Purpose: TREATMENT
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: SPONSOR INVESTIGATOR
• PI Title: Cardiac Electrophysiologist / Principal Investigator

Study Record Dates

• First Submitted: February 8, 2017
• First Posted: February 20, 2017
• Study Start: February 24, 2017
• Primary Completion: May 13, 2020
• Study Completion: May 31, 2020
• Last Updated: November 5, 2025
• Results First Posted: November 5, 2025

Record last verified: 2025-10

Data Sharing

• IPD Sharing: Will not share

Locations

US (1); JP (1)