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Rivera A, Gewehr DM, Braga MAP, Carvalho PEP, Ternes CMP, Pantaleao AN, Hincapie D, Serpa F, Romero JE, d'Avila A. Adjunctive low-voltage area ablation for patients with atrial fibrillation: An updated meta-analysis of randomized controlled trials. J Cardiovasc Electrophysiol 2024; 35:1329-1339. [PMID: 38664888 DOI: 10.1111/jce.16290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 03/29/2024] [Accepted: 04/16/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND The efficacy and safety of adjunctive low-voltage area (LVA) ablation on outcomes of catheter ablation (CA) for atrial fibrillation (AF) remains uncertain. METHODS PubMed, Embase, Cochrane Library, and ClinicalTrials.gov were searched for randomized controlled trials (RCTs) comparing CA with versus without LVA ablation for patients with AF. Risk ratios (RR) with 95% confidence intervals (CI) were pooled with a random-effects model. Our primary endpoint was recurrence of atrial tachyarrhythmia (ATA), including AF, atrial flutter, or atrial tachycardia. We used R version 4.3.1 for all statistical analyses. RESULTS Our meta-analysis included 10 RCTs encompassing 1780 patients, of whom 890 (50%) were randomized to LVA ablation. Adjunctive LVA ablation significantly reduced recurrence of ATA (RR 0.76; 95% CI 0.67-0.88; p < .01) and reduced the number of redo ablation procedures (RR 0.54; 95% CI 0.35-0.85; p < .01), as compared with conventional ablation. Among 691 (43%) patients with documented LVAs on baseline substrate mapping, adjunctive LVA ablation substantially reduced ATA recurrences (RR 0.57; 95% CI 0.38-0.86; p < .01). There was no significant difference between groups in terms of periprocedural adverse events (RR 0.78; 95% CI 0.39-1.56; p = .49). CONCLUSIONS Adjunctive LVA ablation is an effective and safe strategy for reducing recurrences of ATA among patients who undergo CA for AF.
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Affiliation(s)
- André Rivera
- Department of Medicine, Nove de Julho University, São Bernardo do Campo, Brazil
| | | | - Marcelo A P Braga
- Department of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Pedro E P Carvalho
- Center for Coronary Artery Disease, Minneapolis Heart Institute Foundation, Minneapolis, USA
| | - Caique M P Ternes
- Postgraduate Program in Cardiology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Alexandre N Pantaleao
- Department of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniela Hincapie
- Harvard Medical School, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Cardiac Arrhythmia Service, Boston, Massachusetts, USA
| | - Frans Serpa
- Division of Cardiology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jorge E Romero
- Harvard Medical School, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Cardiac Arrhythmia Service, Boston, Massachusetts, USA
| | - André d'Avila
- Harvard Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Segan L, Chieng D, Sugumar H, Voskoboinik A, Ling LH, Costello B, Azzopardi S, Nderitu Z, Parameswaran R, Amerena J, McLellan AJ, Lee G, Morton J, Joseph S, Wong M, Taylor A, Kalman JM, Kistler PM, Prabhu S. The impact of age on ablation outcomes in AF-mediated cardiomyopathy. J Cardiovasc Electrophysiol 2023; 34:2065-2075. [PMID: 37694615 DOI: 10.1111/jce.16052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 08/22/2023] [Accepted: 08/26/2023] [Indexed: 09/12/2023]
Abstract
INTRODUCTION The absence of ventricular scar in patients with atrial fibrillation (AF) and systolic heart failure (HF) predicts left ventricular (LV) recovery following AF ablation. It is unknown whether age impacts the degree of LV recovery, reverse remodeling, or AF recurrence following catheter ablation (CA) among this population. OBJECTIVES To evaluate the impact of age on LV recovery and AF recurrence in a population with AF and systolic HF without fibrosis (termed AF-mediated cardiomyopathy) following CA. METHODS Consecutive patients undergoing CA between 2013 and 2021 with LV ejection fraction (LVEF) < 45% and absence of cardiac magnetic resonance imaging (CMR) detected LV myocardial fibrosis were stratified by age (<65 vs. ≥65 years). Following CA, participants underwent remote rhythm monitoring for 12 months with repeat CMR for HF surveillance. RESULTS The study population consisted of 70 patients (10% female, mean LVEF 33 ± 9%), stratified into younger (age < 65 years, 63%) and older (age ≥ 65 years, 37%) cohorts. Baseline comorbidities, LVEF (34 ± 9 vs. 33 ± 8 ≥65 years, p = .686), atrial and ventricular dimensions (left atrial volume index: 55 ± 21 vs. 56 ± 14 mL/m2 age ≥ 65, p = .834; indexed left ventricular end-diastolic volume: 108 ± 40 vs. 104 ± 28 mL/m2 age ≥ 65, p = .681), pharmacotherapy and ablation strategy (pulmonary vein isolation in all; posterior wall isolation in 27% vs. 19% age ≥ 65, p = .448; cavotricuspid isthmus in 9% vs. 11.5% age ≥ 65) were comparable (all p > .05) albeit a higher CHADS2 VASc score in the older cohort (2.7 ± 0.9 vs. 1.6 ± 0.6 age < 65, p < .001). Freedom from AF was comparable (hazard ratio: 0.65, 95% confidence interval: 0.38-1.48, LogRank p = .283) as was AF burden [0% (interquartile range, IQR: 0.0-2.1) vs. age ≥ 65: [0% (IQR 0.0-1.7), p = .516], irrespective of age. There was a significant improvement in LV systolic function in both groups (ΔLVEF + 21 ± 14% vs. +21 ± 12% age ≥ 65, p = .913), with LV recovery in the vast majority (73% vs. 69%, respectively, p = .759) at 13 (IQR: 12-16) months. This was accompanied by comparable improvements in functional status (New York Heart Association class p = .851; 6-min walk distance 50 ± 61 vs. 93 ± 134 m in age ≥ 65, p = .066), biomarkers (ΔN-terminal-pro brain natriuretic peptide -139 ± 246 vs. -168 ± 181 age ≥ 65,p = .629) and HF symptoms (Short Form-36 survey Δphysical component summary p = .483/Δmental component summary, p = .841). CONCLUSION In patients undergoing CA for AF with systolic HF in the absence of ventricular scar, comparable improvements in ventricular function, symptoms, and freedom from AF are achieved irrespective of age.
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Affiliation(s)
- Louise Segan
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Cabrini Hospital, Melbourne, Australia
| | - David Chieng
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Cabrini Hospital, Melbourne, Australia
| | - Hariharan Sugumar
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Cabrini Hospital, Melbourne, Australia
| | - Aleksandr Voskoboinik
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Cabrini Hospital, Melbourne, Australia
- Western Health, Melbourne, Australia
| | - Liang-Han Ling
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Cabrini Hospital, Melbourne, Australia
| | - Ben Costello
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- Western Health, Melbourne, Australia
| | - Sonia Azzopardi
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
| | - Ziporah Nderitu
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
| | - Ramanathan Parameswaran
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
- Barwon Health, Geelong, Australia
| | | | - Alex J McLellan
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
| | - Geoffrey Lee
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
| | - Joseph Morton
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
| | | | - Michael Wong
- University of Melbourne, Melbourne, Australia
- Western Health, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
| | | | - Jonathan M Kalman
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
| | - Peter M Kistler
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Cabrini Hospital, Melbourne, Australia
| | - Sandeep Prabhu
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
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3
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Chieng D, Sugumar H, Segan L, Tan C, Vizi D, Nanayakkara S, Al-Kaisey A, Hawson J, Prabhu S, Voskoboinik A, Finch S, Morton JB, Lee G, Mariani J, La Gerche A, Taylor AJ, Howden E, Kistler PM, Kalman JM, Kaye DM, Ling LH. Atrial Fibrillation Ablation for Heart Failure With Preserved Ejection Fraction: A Randomized Controlled Trial. JACC. HEART FAILURE 2023; 11:646-658. [PMID: 36868916 DOI: 10.1016/j.jchf.2023.01.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 12/23/2022] [Accepted: 01/04/2023] [Indexed: 03/05/2023]
Abstract
BACKGROUND Patients with heart failure with preserved ejection fraction (HFpEF) frequently develop atrial fibrillation (AF). There are no randomized trials examining the effects of AF ablation on HFpEF outcomes. OBJECTIVES The aim of this study is to compare the effects of AF ablation vs usual medical therapy on markers of HFpEF severity, including exercise hemodynamics, natriuretic peptide levels, and patient symptoms. METHODS Patients with concomitant AF and HFpEF underwent exercise right heart catheterization and cardiopulmonary exercise testing. HFpEF was confirmed with pulmonary capillary wedge pressure (PCWP) of 15 mm Hg at rest or ≥25 mm Hg on exercise. Patients were randomized to AF ablation vs medical therapy, with investigations repeated at 6 months. The primary outcome was change in peak exercise PCWP on follow-up. RESULTS A total of 31 patients (mean age: 66.1 years; 51.6% females, 80.6% persistent AF) were randomized to AF ablation (n = 16) vs medical therapy (n = 15). Baseline characteristics were comparable across both groups. At 6 months, ablation reduced the primary outcome of peak PCWP from baseline (30.4 ± 4.2 to 25.4 ± 4.5 mm Hg; P < 0.01). Improvements were also seen in peak relative VO2 (20.2 ± 5.9 to 23.1 ± 7.2 mL/kg/min; P < 0.01), N-terminal pro-B-type natriuretic peptide levels (794 ± 698 to 141 ± 60 ng/L; P = 0.04), and MLHF (Minnesota Living with Heart Failure) score (51 ± -21.9 to 16.6 ± 17.5; P < 0.01). No differences were detected in the medical arm. Following ablation, 50% no longer met exercise right heart catheterization-based criteria for HFpEF vs 7% in the medical arm (P = 0.02). CONCLUSIONS AF ablation improves invasive exercise hemodynamic parameters, exercise capacity, and quality of life in patients with concomitant AF and HFpEF.
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Affiliation(s)
- David Chieng
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - Hariharan Sugumar
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - Louise Segan
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - Caleb Tan
- Department of Cardiology, Alfred Hospital, Melbourne, Australia
| | - Donna Vizi
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia
| | - Shane Nanayakkara
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia
| | - Ahmed Al-Kaisey
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; University of Melbourne, Melbourne, Australia; Royal Melbourne Hospital, Melbourne, Australia
| | - Joshua Hawson
- University of Melbourne, Melbourne, Australia; Royal Melbourne Hospital, Melbourne, Australia
| | - Sandeep Prabhu
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - Aleksandr Voskoboinik
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - Sue Finch
- University of Melbourne, Melbourne, Australia
| | - Joseph B Morton
- University of Melbourne, Melbourne, Australia; Royal Melbourne Hospital, Melbourne, Australia
| | - Geoffrey Lee
- University of Melbourne, Melbourne, Australia; Royal Melbourne Hospital, Melbourne, Australia
| | - Justin Mariani
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
| | - Andre La Gerche
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - Andrew J Taylor
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - Erin Howden
- Department of Cardiology, Alfred Hospital, Melbourne, Australia
| | - Peter M Kistler
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia; Monash University, Melbourne, Australia
| | - Jonathan M Kalman
- University of Melbourne, Melbourne, Australia; Royal Melbourne Hospital, Melbourne, Australia; Monash University, Melbourne, Australia
| | - David M Kaye
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia; Monash University, Melbourne, Australia.
| | - Liang-Han Ling
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia.
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Kistler PM, Chieng D, Sugumar H, Ling LH, Segan L, Azzopardi S, Al-Kaisey A, Parameswaran R, Anderson RD, Hawson J, Prabhu S, Voskoboinik A, Wong G, Morton JB, Pathik B, McLellan AJ, Lee G, Wong M, Finch S, Pathak RK, Raja DC, Sterns L, Ginks M, Reid CM, Sanders P, Kalman JM. Effect of Catheter Ablation Using Pulmonary Vein Isolation With vs Without Posterior Left Atrial Wall Isolation on Atrial Arrhythmia Recurrence in Patients With Persistent Atrial Fibrillation: The CAPLA Randomized Clinical Trial. JAMA 2023; 329:127-135. [PMID: 36625809 PMCID: PMC9856612 DOI: 10.1001/jama.2022.23722] [Citation(s) in RCA: 106] [Impact Index Per Article: 106.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
IMPORTANCE Pulmonary vein isolation (PVI) alone is less effective in patients with persistent atrial fibrillation (AF) compared with paroxysmal AF. The left atrial posterior wall may contribute to maintenance of persistent AF, and posterior wall isolation (PWI) is a common PVI adjunct. However, PWI has not been subjected to randomized comparison. OBJECTIVE To compare PVI with PWI vs PVI alone in patients with persistent AF undergoing first-time catheter ablation. DESIGN, SETTING, AND PARTICIPANTS Investigator initiated, multicenter, randomized clinical trial involving 11 centers in 3 countries (Australia, Canada, UK). Symptomatic patients with persistent AF were randomized 1:1 to either PVI with PWI or PVI alone. Patients were enrolled July 2018-March 2021, with 1-year follow-up completed March 2022. INTERVENTIONS The PVI with PWI group (n = 170) underwent wide antral pulmonary vein isolation followed by posterior wall isolation involving linear ablation at the roof and floor to achieve electrical isolation. The PVI-alone group (n = 168) underwent wide antral pulmonary vein isolation alone. MAIN OUTCOMES AND MEASURES Primary end point was freedom from any documented atrial arrhythmia of more than 30 seconds without antiarrhythmic medication at 12 months, after a single ablation procedure. The 23 secondary outcomes included freedom from atrial arrhythmia with/without antiarrhythmic medication after multiple procedures, freedom from symptomatic AF with/without antiarrhythmic medication after multiple procedures, AF burden between study groups at 12 months, procedural outcomes, and complications. RESULTS Among 338 patients randomized (median age, 65.6 [IQR, 13.1] years; 76.9% men), 330 (97.6%) completed the study. After 12 months, 89 patients (52.4%) assigned to PVI with PWI were free from recurrent atrial arrhythmia without antiarrhythmic medication after a single procedure, compared with 90 (53.6%) assigned to PVI alone (between-group difference, -1.2%; hazard ratio [HR], 0.99 [95% CI, 0.73-1.36]; P = .98). Of the secondary end points, 9 showed no significant difference, including freedom from atrial arrhythmia with/without antiarrhythmic medication after multiple procedures (58.2% for PVI with PWI vs 60.1% for PVI alone; HR, 1.10 [95% CI, 0.79-1.55]; P = .57), freedom from symptomatic AF with/without antiarrhythmic medication after multiple procedures (68.2% vs 72%; HR, 1.20 [95% CI, 0.80-1.78]; P = .36) or AF burden (0% [IQR, 0%-2.3%] vs 0% [IQR, 0%-2.8%], P = .47). Mean procedural times (142 [SD, 69] vs 121 [SD, 57] minutes, P < .001) and ablation times (34 [SD, 21] vs 28 [SD, 12] minutes, P < .001) were significantly shorter for PVI alone. There were 6 complications for PVI with PWI and 4 for PVI alone. CONCLUSIONS AND RELEVANCE In patients undergoing first-time catheter ablation for persistent AF, the addition of PWI to PVI alone did not significantly improve freedom from atrial arrhythmia at 12 months compared with PVI alone. These findings do not support the empirical inclusion of PWI for ablation of persistent AF. TRIAL REGISTRATION anzctr.org.au Identifier: ACTRN12616001436460.
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Affiliation(s)
- Peter M. Kistler
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Cabrini Hospital, Melbourne, Australia
- Monash Health, Melbourne, Australia
- Melbourne Private Hospital, Melbourne, Australia
| | - David Chieng
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Cabrini Hospital, Melbourne, Australia
| | - Hariharan Sugumar
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Cabrini Hospital, Melbourne, Australia
| | - Liang-Han Ling
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Cabrini Hospital, Melbourne, Australia
| | - Louise Segan
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Cabrini Hospital, Melbourne, Australia
| | - Sonia Azzopardi
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
| | - Ahmed Al-Kaisey
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
| | | | - Robert D. Anderson
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
| | - Joshua Hawson
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
| | - Sandeep Prabhu
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Mulgrave Private Hospital, Melbourne, Australia
| | - Aleksandr Voskoboinik
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Cabrini Hospital, Melbourne, Australia
| | - Geoffrey Wong
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
| | - Joseph B. Morton
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
| | - Bhupesh Pathik
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
| | - Alex J. McLellan
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
- St Vincent’s Private Hospital Fitzroy, Melbourne, Australia
| | - Geoffrey Lee
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
| | - Michael Wong
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
- Epworth Hospital Richmond, Melbourne, Australia
| | - Sue Finch
- University of Melbourne, Melbourne, Australia
| | - Rajeev K. Pathak
- Canberra Hospital, Australian Capital Territory, Australia
- Australian National University, Australian Capital Territory, Australia
| | - Deep Chandh Raja
- Canberra Hospital, Australian Capital Territory, Australia
- Australian National University, Australian Capital Territory, Australia
| | - Laurence Sterns
- Royal Jubilee Hospital, Vancouver Island, British Columbia, Canada
| | | | | | | | - Jonathan M. Kalman
- University of Melbourne, Melbourne, Australia
- Monash Health, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
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5
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Chieng D, Sugumar H, Ling LH, Segan L, Azzopardi S, Prabhu S, Al-Kaisey A, Voskoboinik A, Parameswaran R, Morton JB, Pathik B, McLellan AJ, Lee G, Wong M, Finch S, Pathak RK, Raja DC, Sanders P, Sterns L, Ginks M, Reid CM, Kalman JM, Kistler PM. Catheter ablation for persistent atrial fibrillation: A multicenter randomized trial of pulmonary vein isolation (PVI) versus PVI with posterior left atrial wall isolation (PWI) - The CAPLA study. Am Heart J 2022; 243:210-220. [PMID: 34619143 DOI: 10.1016/j.ahj.2021.09.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 09/28/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The success of pulmonary vein isolation (PVI) is reduced in persistent AF (PsAF) compared to paroxysmal AF. Adjunctive ablation strategies have failed to show consistent incremental benefit over PVI alone in randomized studies. The left atrial posterior wall is a potential source of non-PV triggers and atrial substrate which may promote the initiation and maintenance of PsAF. Adding posterior wall isolation (PWI) to PVI had shown conflicting outcomes, with earlier studies confounded by methodological limitations. OBJECTIVES To determine whether combining PWI with PVI significantly improves freedom from AF recurrence, compared to PVI alone, in patients with PsAF. METHODS This is a multi-center, prospective, international randomized clinical trial. 338 patients with symptomatic PsAF refractory to anti-arrhythmic therapy (AAD) will be randomized to either PVI alone or PVI with PWI in a 1:1 ratio. PVI involves wide antral circumferential pulmonary vein (PV) isolation, utilizing contact force sensing ablation catheters. PWI involves the creation of a floor line connecting the inferior aspect of the PVs, and a roof line connecting the superior aspect of the PVs. Follow up is for a minimum of 12 months with rhythm monitoring via implantable cardiac device and/or loop monitor, or frequent intermittent monitoring with an ECG device. The primary outcome is freedom from any documented atrial arrhythmia of > 30 seconds off AAD at 12 months, after a single ablation procedure. CONCLUSIONS This randomized study aims to determine the success and safety of adjunctive PWI to PVI in patients with persistent AF.
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Affiliation(s)
- David Chieng
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia; The Alfred Hospital, Melbourne, Australia,; University of Melbourne, Melbourne, Australia; Cabrini Hospital, Melbourne, Australia
| | - Hariharan Sugumar
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia; The Alfred Hospital, Melbourne, Australia,; University of Melbourne, Melbourne, Australia; Cabrini Hospital, Melbourne, Australia
| | - Liang-Han Ling
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia; The Alfred Hospital, Melbourne, Australia,; University of Melbourne, Melbourne, Australia; St Vincent's Private Hospital Fitzroy, Melbourne Australia
| | - Louise Segan
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia; The Alfred Hospital, Melbourne, Australia,; University of Melbourne, Melbourne, Australia; Cabrini Hospital, Melbourne, Australia
| | - Sonia Azzopardi
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia; The Alfred Hospital, Melbourne, Australia
| | - Sandeep Prabhu
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia; The Alfred Hospital, Melbourne, Australia,; University of Melbourne, Melbourne, Australia; Mulgrave Private Hospital, Melbourne, Australia
| | - Ahmed Al-Kaisey
- University of Melbourne, Melbourne, Australia; Royal Melbourne Hospital, Melbourne, Australia
| | - Aleksandr Voskoboinik
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia; The Alfred Hospital, Melbourne, Australia,; University of Melbourne, Melbourne, Australia; Cabrini Hospital, Melbourne, Australia
| | - Ramanathan Parameswaran
- University of Melbourne, Melbourne, Australia; Royal Melbourne Hospital, Melbourne, Australia
| | - Joseph B Morton
- University of Melbourne, Melbourne, Australia; Royal Melbourne Hospital, Melbourne, Australia
| | - Bhupesh Pathik
- University of Melbourne, Melbourne, Australia; Royal Melbourne Hospital, Melbourne, Australia
| | - Alex J McLellan
- University of Melbourne, Melbourne, Australia; Royal Melbourne Hospital, Melbourne, Australia; St Vincent's Private Hospital Fitzroy, Melbourne Australia
| | - Geoffrey Lee
- University of Melbourne, Melbourne, Australia; Royal Melbourne Hospital, Melbourne, Australia
| | - Michael Wong
- University of Melbourne, Melbourne, Australia; Royal Melbourne Hospital, Melbourne, Australia; Epworth Hospital Richmond, Melbourne, Australia
| | - Sue Finch
- University of Melbourne, Melbourne, Australia
| | - Rajeev K Pathak
- Canberra Hospital, ACT, Australia; Australian National University, ACT, Australia
| | - Deep Chandh Raja
- Canberra Hospital, ACT, Australia; Australian National University, ACT, Australia
| | | | - Laurence Sterns
- Royal Jubilee Hospital, Vancouver Island, British Columbia, Canada
| | | | - Christopher M Reid
- Monash University, Melbourne, Australia; Curtin University, Perth, Australia
| | - Jonathan M Kalman
- University of Melbourne, Melbourne, Australia; Monash University, Melbourne, Australia; Royal Melbourne Hospital, Melbourne, Australia
| | - Peter M Kistler
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia; The Alfred Hospital, Melbourne, Australia,; University of Melbourne, Melbourne, Australia; Cabrini Hospital, Melbourne, Australia; Monash University, Melbourne, Australia; Melbourne Private Hospital, Melbourne, Australia.
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