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BELIEF: LAA isolation during catheter ablation benefited patients with longstanding persistent AF
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LONDON — Isolating the left atrial appendage during catheter ablation was associated with a greater rate of freedom from recurrence of atrial fibrillation in patients with longstanding persistent AF, according to results from the BELIEF study.
The BELIEF study included 173 patients with longstanding persistent AF for whom antiarrhythmic drugs did not work randomized to ablation plus empirical electrical LAA isolation or ablation of the pulmonary vein antrum plus non-pulmonary vein trigger ablation.
The primary outcome was recurrence of AF or atrial tachyarrythmia (AT) lasting longer than 30 seconds.
Outcomes were initially assessed at 12 months. Twenty-seven patients in the LAA isolation group and 35 in the control group underwent a second catheter ablation procedure within 12 months, during which all had LAA electrical isolation. Luigi Di Biase, MD, PhD, FACC, FHRS, and colleagues assessed the outcomes again at 24 months.
Luigi Di Biase
Because of technical difficulties, the LAA could not be isolated in 11 patients from the LAA isolation group, and mean radiofrequency time was longer in the LAA isolation group (93.1 minutes vs. 77.4 minutes; P < .001), Di Biase said.
At 12 months, freedom from recurrent AF or AT occurred in 56% of the LAA isolation group vs. 25% of the control group (HR = 1.92; 95% CI, 1.3-2.9). At 24 months, after a mean of 1.3 procedures in the entire cohort, freedom from recurrent AF or AT occurred in 76% of the LAA isolation group vs. 56% of the control group (HR = 2.24; 95% CI, 1.3-3.8), according to data presented.
After adjustment for age, sex and left atrial diameter, standard ablation plus LAA isolation was associated with a 55% reduction in AF or AT recurrence (HF = 0.45; 95% CI, 0.26-0.77), Di Biase said.
The data demonstrated no significant differences between the groups in hospitalization or stroke/transient ischemic attack. No deaths occurred during the study period, according to the researchers.
“The results of this randomized study show that both after a single procedure and a redo procedure in patients with longstanding persistent AF, the empirical isolation of the LAA improves the long-term freedom from atrial arrhythmias without increasing complications,” said Di Biase, section head of electrophysiology at Albert Einstein and Montefiore Hospital, Bronx, New York, associate professor at the Albert Einstein College of Medicine at Montefiore Hospital and senior researcher at Texas Cardiac Arrhythmia Institute at St. David’s Medical Center, Austin, Texas. “Future studies examining the physiopathology of these findings are necessary.” – by Erik Swain
Reference:
Di Biase L, et al. Hot Line II: Atrial Fibrillation/Pacing. Presented at: European Society of Cardiology Congress; Aug. 29-Sept. 2, 2015; London.
Disclosure: Di Biase reports consulting for Biosense Webster, Stereotaxis and St. Jude Medical and receiving speaker honoraria/travel from Atricure, Biotronik, Boston Scientific, Epi EP and Medtronic.
Perspective
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Elliott Antman, MD, FAHA
LAA electrical isolation in the BELIEF study improved the likelihood that you would be free of recurrent AF, but it was not complete freedom from AF. I do not think that the cumulative 75% success rate after a follow-up procedure was a sufficiently high success rate, and a follow-up of 1 year was not sufficiently long to convince me that we can safely stop oral anticoagulation. The benefits of the additional electrical isolation would certainly be helpful in patients who have symptomatic recurrences and don’t want to have them for quality-of-life reasons, but I would be concerned about discontinuing oral anticoagulation.
Dr. Di Biase pointed out that he goes through some special additional testing, transesophageal echocardiography and evaluates the mechanical function of the atrial appendage over the long term, but what we need to see is a larger number of patients and a longer follow-up to be sure of that.
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