Catheter ablation of persistent atrial fibrillation : Beneficial effect of a short-term adjunctive amiodarone therapy on the long-term outcome

Blanking period antiarrhythmic drugs after catheter ablation for atrial fibrillation: a meta-analysis of randomized controlled trials

Background

Antiarrhythmic drugs (AADs) are frequently prescribed following catheter ablation (CA) for atrial fibrillation (AF). However, to date, there is a lack of large-scale, multicenter controlled studies that have confirmed the efficacy of AADs in reducing the incidence of late recurrence of AF after CA. Furthermore, the optimal duration of short-term use of AADs after CA remains a controversial topic.

Methods

PubMed, Embase, Cochrane Library, CNKI, and ClinicalTrials.gov were searched until April 25, 2022. We conducted a meta-analysis of randomized controlled trials (RCTs) to assess the efficacy of blanking period AADs in predicting both early and late recurrence of AF. In addition, Grading of Recommendations Assessment, Development and Evaluation (GRADE) was used to assess the quality of evidence in this meta-analysis.

Results

12 RCTs with 3,625 patients were included in this meta-analysis. Short-term use of AADs after AF ablation reduced the risk of early recurrence of AF compared with the no-AADs group. In the subgroup analysis of AADs use time, it was found that only using AADs for more than 2 months can reduce the early recurrence of AF after CA. However, when compared with the no-AADs group, short-term use of AADs after CA did not reduce the incidence of late recurrence of AF.

Conclusions

Short-term use of AADs (more than 2 months) can reduce the early recurrence but not the late recurrence of AF after CA.

Oral Class I and III antiarrhythmic drugs for maintaining sinus rhythm after catheter ablation of atrial fibrillation

BACKGROUND

Recurrence of atrial tachyarrhythmias (ATa) following catheter ablation for atrial fibrillation (AF) is a common problem. Antiarrhythmic drugs have been used shortly after ablation in an attempt to maintain sinus rhythm, particularly Class I and III agents. However, it still needs to be established if the use of Class I or III antiarrhythmic medications, or both, reduce the risk of recurrence of ATa.

OBJECTIVES

To assess the effects of oral Class I and III antiarrhythmic drugs versus control (standard medical therapy without Class I or III antiarrhythmics, or placebo) for maintaining sinus rhythm in people undergoing catheter ablation for AF.

SEARCH METHODS

We systematically searched CENTRAL, MEDLINE, Embase, Web of Science Core Collection, and two clinical trial registers without restrictions on language or date to 5 August 2022.

SELECTION CRITERIA

We sought published, unpublished, and ongoing parallel-design, randomised controlled trials (RCTs) involving adult participants undergoing ablation for AF, with subsequent comparison of Class I and/or III antiarrhythmic use versus control (standard medical therapy or non-Class I and/or III antiarrhythmic use).

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane and performed meta-analyses with risk ratios (RR) and Peto odds ratios (Peto OR). Our primary outcomes were recurrence of atrial tachyarrhythmias; adverse events: thromboembolic events; adverse events: myocardial infarction; adverse events: new diagnosis of heart failure; and adverse events: requirement for one or more hospitalisations for atrial tachyarrhythmia. Our secondary outcomes were: all-cause mortality; and requirement for one or more repeat ablations. Where possible, we performed comparison analysis by Class I and/or III antiarrhythmic and divided follow-up periods for our primary outcome. We performed comprehensive assessments of risk of bias and certainty of evidence applying the GRADE methodology.

MAIN RESULTS

We included nine RCTs involving a total of 3269 participants. Participants were on average 59.3 years old; 71.0% were male; and 72.9% and 27.4% had paroxysmal and persistent AF, respectively. Class I and/or III antiarrhythmics may reduce recurrence of ATa at 0 to 3 months postablation (risk ratio (RR) 0.74, 95% confidence interval (CI) 0.59 to 0.94, 8 trials, 3046 participants, low-certainty evidence) and likely reduce recurrence at > 3 to 6 months, our a priori primary time point (RR 0.85, 95% CI 0.78 to 0.93, 5 trials, 2591 participants, moderate-certainty evidence). Beyond six months the evidence is very uncertain, and the benefit of antiarrhythmics may not persist (RR 1.14, 95% CI 0.84 to 1.55, 4 trials, 2244 participants, very low-certainty evidence). The evidence suggests that Class I and/or III antiarrhythmics may not increase the risk of thromboembolic events, myocardial infarction, all-cause mortality, or requirement for repeat ablation, at 0 to 3, > 3 to 6, and > 6 months (where data were available; low- to very low-certainty evidence). The use of Class I and/or III antiarrhythmics postablation likely reduces hospitalisations for ATa by approximately 57% at 0 to 3 months (RR 0.43, 95% CI 0.28 to 0.64, moderate-certainty evidence). No data were available beyond three months. No data were available on new diagnoses of heart failure. Fewer data were available for Class I and III antiarrhythmics individually. Based on only one and two trials (n = 125 to 309), Class I antiarrhythmics may have little effect on recurrence of ATa at 0 to 3, > 3 to 6, and > 6 months (RR 0.88, 95% CI 0.64 to 1.20, 2 trials, 309 participants; RR 0.54, 95% CI 0.25 to 1.19, 1 trial, 125 participants; RR 0.87, 95% CI 0.57 to 1.32, 1 trial, 125 participants; low-certainty evidence throughout); requirement for hospitalisation for ATa at 0 to 3 months (low-certainty evidence); or requirement for repeat ablation at 0 to 3 months (low-certainty evidence). No data were available for thromboembolic events, myocardial infarction, new diagnosis of heart failure, or all-cause mortality at any time points, or hospitalisation or repeat ablation beyond three months. Class III antiarrhythmics may have little effect on recurrence of ATa at up to 3 months and at > 3 to 6 months (RR 0.76, 95% CI 0.50 to 1.16, 4 trials, 599 participants, low-certainty evidence; RR 0.82, 95% CI 0.62 to 1.09, 2 trials, 318 participants, low-certainty evidence), and beyond 6 months one trial reported a possible increase in recurrence of ATa (RR 1.95, 95% CI 1.29 to 2.94, 1 trial, 112 participants, low-certainty evidence). Class III antiarrhythmics likely reduce hospitalisations for ATa at 0 to 3 months (RR 0.40, 95% CI 0.26 to 0.63, moderate-certainty evidence), and may have little effect on all-cause mortality (low- to very low-certainty evidence). The effect of Class III antiarrhythmics on thromboembolic events and requirement for repeat ablation was uncertain (very low-certainty evidence for both outcomes). No data were available for myocardial infarction or new diagnosis of heart failure at any time point, outcomes other than recurrence beyond 6 months, or for hospitalisation and repeat ablation > 3 to 6 months. We assessed the majority of included trials as at low or unclear risk of bias. One trial reported an error in the randomisation process, raising the potential risk of selection bias; most of the included trials were non-blinded; and two trials were at high risk of attrition bias.

AUTHORS' CONCLUSIONS

We found evidence to suggest that the use of Class I and/or III antiarrhythmics up to 3 months after ablation is associated with a reduced recurrence of ATa 0 to 6 months after ablation, which may not persist beyond 6 months, and an immediate reduction in hospitalisation for ATa 0 to 3 months after ablation. The evidence suggests there is no difference in rates of all-cause mortality, thromboembolic events, or myocardial infarction between Class I and/or III antiarrhythmics versus control.

Effect of perioperative intravenous amiodarone on cardioversion of atrial fibrillation early after video-assisted thoracoscopic surgical ablation: Study protocol for a double-blind randomized controlled trial

Introduction

Video-assisted thoracoscopic surgical (VATS) ablation is widely performed in surgical areas to treat atrial fibrillation (AF), which is minimally invasive and highly effective. Amiodarone, known as a class III antiarrhythmic agent, has the greatest potential to maintain sinus rhythm of AF. At present, few studies focused on the efficacy of perioperative intravenous amiodarone in the VATS ablation of AF. Therefore, the trial is designed to investigate the effect of perioperative amiodarone infusion on cardioversion of AF early after VATS ablation.

Methods

and analysis: This will be a prospective, randomized, double-blind, controlled trial. The trial is to enroll 182 patients aged 18–70 years who will undergo VATS ablation of AF. All eligible participants will be randomly allocated to either the amiodarone or placebo group by using the block randomization in a 1:1 ratio. The primary endpoint will be freedom from atrial arrhythmias 24 h after the VATS procedure and be assessed using the Kaplan-Meier method. All data will be analyzed in accordance with the intention-to-treat principle.

Discussion

The clinical trial has been designed to investigate the efficacy of perioperative intravenous amiodarone on cardioversion of AF early after VATS ablation. We are hoping to demonstrate that perioperative infusion of amiodarone could improve the maintenance of sinus rhythm 24 h after VATS ablation.

Knots to untie: anticoagulant and antiarrhythmic therapy after ablation for atrial fibrillation

The continuation or otherwise of anticoagulant and antiarrhythmic therapy after ablation of atrial fibrillation (AF) is one of the main aspects still to be defined in the electrophysiological field. The currently available data do not allow the assumption of certain positions due to the lack of randomized studies on the subject. With regard to anticoagulant therapy, however, the suggestion of the guidelines to assess more the risk profile than the result of the ablation and consequently to prescribe anticoagulant treatment to all patients with CHADSVASc ≥2 seems acceptable. Its use in the first two or three months after the procedure appears reasonable; however, keeping in mind that the objective of this strategy is limited to the prevention of early recurrences only. More prolonged use of antiarrhythmics seems to be more promising, but further data are necessary before it can be recommended routinely. The ablation of AF is a therapy that is widely spreading and its use is continuously growing. Since it is a recently introduced method, not everything is still clear about it. The continuation or not of anticoagulant and antiarrhythmic therapy after ablation for AF is one of the main aspects yet to be defined.