Aims To investigate the impact of variant pulmonary vein (PV) anatomy and the use of three-dimensional image integration (3D-II) on long-term efficacy of catheter ablation for atrial fibrillation (AF). Methods Consecutive procedures from 2002 to 2007 were analysed from a prospective database. All patients underwent wide area circumferential ablation, with linear lesions added and complex fractionated electrograms targeted for persistent AF. Imaging was segmented on Carto to assess PV anatomy.

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... sults Three hundred and fifty patients underwent 1.9 + 0.9 procedures. The mean age was 57 + 11 years, 73% males, and 55% paroxysmal AF. Freedom from AF/atrial tachycardia was 42% for paroxysmal AF and 20% for persistent AF at 3.1 years after the first procedure, or 86 and 66%, respectively, at 2.5 years after the last procedure. The Kaplan-Meier analysis showed a trend towards improved single-procedure efficacy with 3D-II (8.9% difference, P ¼ 0.087) and a reduction in the number of procedures per patient from 2.1 + 1.1 to 1.8 + 0.9 (P , 0.0001). The use of 3D-II improved single-procedure efficacy with Carto (13.3% difference, P ¼ 0.018), but not with Ensite NavX. Variant PV anatomy was identified in 28% and was associated with a lower single-procedure efficacy (10.0% difference, P ¼ 0.024) but with no effect on final outcome. Multivariate analysis confirmed the impact of 3D-II [hazard ratio (HR) for recurrence of AF 0.67, P ¼ 0.020] and variant PV anatomy (HR 1.37, P ¼ 0.044). Conclusion The use of 3D-II improves single-procedure efficacy of PV isolation for AF. Variant PV anatomy was associated with a lower single-procedure success rate. ---