Quick answer
In paroxysmal atrial fibrillation, isolating the pulmonary veins is enough. In persistent AF the veins are only part of the substrate, and two decades of trials adding lines, boxes and complex fractionated ablation failed to beat vein isolation alone. PROMPT-AF, led by Ma Changsheng at Beijing Anzhen Hospital with Jiang Chenyang of Sir Run Run Shaw Hospital, tested a specific, optimised version of the linear strategy. Adding three lines plus ethanol infusion into the Marshall vein raised 12-month freedom from atrial arrhythmia without antiarrhythmic drugs from 61.5% to 70.7%. It was published in JAMA [1][3][6].
Key takeaways
- Design: multicentre randomised clinical trial at 12 Chinese tertiary hospitals [6].
- Population: 498 patients undergoing first ablation for persistent AF [3][6].
- Intervention: modified 2C3L — pulmonary vein isolation, two circumferential plus three linear lesions — combined with Marshall vein ethanol infusion [1][3].
- Primary outcome: 12-month freedom from atrial arrhythmia off antiarrhythmic drugs, 70.7% versus 61.5% [2].
- Corresponding authors Ma Changsheng and Jiang Chenyang; first authors Sang Caihua, Liu Qiang, Lai Yiwei, Xia Shijun, Jiang Ruhong and Li Songnan [6].
Why previous linear ablation failed
The 2C3L set — circumferential isolation plus roof, mitral isthmus and cavotricuspid isthmus lines — has been used in China for years. What changed here is the emphasis on optimising the lines: verifying block, and adding Marshall vein ethanol infusion to close the mitral isthmus region, which is where linear lesions most often fail to achieve durable block [1][4].
The distinction matters: the trial did not show that "more ablation is better", it showed that a specific adjunct closing a known anatomical gap improves outcomes. That is a narrower and more defensible claim than the failed substrate-modification trials of the past [3][6].
Reading the 9-point gain
A nine percentage-point absolute improvement in drug-free freedom from AF at 12 months is clinically meaningful, and it is roughly the size of benefit reported for other adjunctive strategies. The trial was also selected as a late-breaking trial at the American Heart Association and named among China's ten major cardiovascular studies of 2025 [3][4].
Arrhythmia recurrence after persistent AF ablation continues beyond the first year, so the durability of the incremental benefit is unknown. Freedom from AF is a rhythm endpoint, not a hard outcome: no trial in this field has shown that an incremental ablation strategy reduces stroke or mortality. The procedure is longer, requires ethanol infusion skills, and carries additional risks at the linear lesions and the Marshall vein. Whether the 30% of patients who still recur can be identified pre-procedure — by substrate mapping, as the Anzhen group is now exploring — is the next question [2][4][5].
The condition in context: persistent AF
Persistent AF is commoner in older patients with structural heart disease, and ablation outcomes are worse than in paroxysmal disease.
| Region | What the data shows | Source |
|---|---|---|
| Residual risk | Even with 2C3L and Marshall ethanol, about 30% recur within a year [4]. | DrVoice [4] |
| Prior evidence | Adding ablation beyond vein isolation had not reliably improved outcomes before this trial [1][3]. | Health News [1][3] |
| Recognition | Named among China's ten major cardiovascular clinical studies of 2025 [4]. | DrVoice [4] |
Because persistent AF carries a higher stroke and heart-failure burden, a durable rhythm strategy has value beyond symptom relief [3].
Why it matters
| Potential | What the report suggests | Source |
|---|---|---|
| Effect size | 70.7% versus 61.5% drug-free freedom at 12 months [2]. | [2] |
| First Chinese technique | First original Chinese ablation strategy published in JAMA [3]. | [3] |
| Caution | Rhythm endpoint; long-term durability unknown [2][4]. | [2][4] |
Availability and limits
- This is an editorial summary of the publication, not a treatment recommendation [1][3].
- The strategy requires Marshall vein ethanol infusion expertise [4].
- No mortality or stroke benefit has been demonstrated [2].
- Follow-up beyond 12 months is not reported here [6].
- Re-do ablation after recurrence is a separate decision [4].
What to ask before booking
| Question | Why it matters |
|---|---|
| Is my AF paroxysmal or persistent, and for how long? | Duration affects the substrate and the expected success rate [3]. |
| Will linear lesions be verified for block? | Block verification is central to this strategy [1]. |
| Which department handles foreign patients, and in what language? | Anzhen is a working hospital we do not book; confirm international-department coordination and language support. |
| How will arrhythmia recurrence be monitored after 12 months? | Recurrence continues beyond the trial horizon [4]. |
Questions patients ask
What did PROMPT-AF test?
Modified 2C3L ablation — pulmonary vein isolation with two circumferential and three linear lesions plus Marshall vein ethanol infusion — versus pulmonary vein isolation alone, in first-time ablation for persistent AF [1][3].
What was the result?
Twelve-month freedom from atrial arrhythmia without antiarrhythmic drugs was 70.7% versus 61.5% [2].
How many patients?
498 patients across 12 Chinese tertiary hospitals [3][6].
Where was it published?
JAMA, 2025, with Ma Changsheng and Jiang Chenyang as corresponding authors [1][6].
Is this relevant to international patients?
It is useful context for China's AF ablation practice. Anzhen is a working hospital we do not book — contact its international department directly [1].