Surgical ablation not superior to catheter ablation in long-standing persistent AF
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Thoracoscopic surgical ablation for long-standing persistent atrial fibrillation was not superior to catheter ablation in freedom from arrhythmia of at least 30 seconds or burden reduction of at least 75%, researchers reported.
According to results from the CASA-AF trial presented at the virtual European Society of Cardiology Congress, catheter ablation resulted in better European Heart Rhythm Association (EHRA) scores for AF, more quality-adjusted life-years and lower total costs compared with surgical ablation.
The findings were simultaneously published in the European Heart Journal.
“Long-standing persistent atrial fibrillation is a significant evidence gap in the literature, and this is well recognized in international guidelines. What is the optimal interventional first-line strategy for long-standing persistent AF is unknown,” Shouvik Haldar, MD(Res), MRCP, consultant cardiologist and electrophysiologist at the Royal Brompton and Harefield NHS Foundation Trust in London, said during a presentation. “Therefore, our study objective was to determine whether thoracoscopic surgical ablation was superior to catheter ablation as a first-line procedure in drug refractory, de novo, long-standing persistent AF patients.
“We found that thoracoscopic surgical ablation was not superior to catheter ablation in establishing and maintaining normal sinus rhythm in this group,” Haldar said. “We therefore recommend catheter ablation as the first-line interventional therapy for patients with symptomatic, long-standing persistent atrial fibrillation, refractory to drug therapy.”
Investigators randomly assigned 120 adult patients with long-standing persistent AF, EHRA score of more than 2 and left ventricular ejection fraction of at least 40% to undergo go surgical or catheter ablation. The primary endpoint was single procedure freedom from AF or atrial tachycardia no less than 30 seconds without antiarrhythmic drugs at 12 months. Secondary endpoints included differences in procedure-related adverse events, reduction in arrhythmia burden of at least 75%, EHRA score, QALYs and health care costs.
Catheter vs. surgical ablation at 12 months
After 12 months of follow-up, researchers found no difference between surgical or catheter ablation for freedom from AF or atrial tachycardia of at least 30 seconds (26% vs. 28%, respectively; OR = 1.128; 95% CI, 0.46-2.82).
Although catheter ablation trended toward better arrhythmia burden reduction compared with surgical ablation (77% vs. 67%), the difference was not statistically significant (OR = 1.13; 95% CI, 0.67-4.08).
“Given that these patients were highly symptomatic and in continuous AF for 2 years, this reduction in AF burden provided significant clinical benefit as demonstrated by the improvement from baseline in quality of life measures,” Haldar and colleagues wrote in the simultaneous publication. “The AF burden reduction may be a better indicator of positive clinical outcomes and therefore the use of continuous cardiac monitoring to accurately assess the burden of arrhythmia pre- and post-ablation is desirable.”
Researchers reported no significant difference between surgical and catheter ablation groups for serious adverse events within 30 days of follow-up (15% vs. 10%; P = .46). However, the incidence of procedure-related adverse events at 12 months was greater among patients who underwent surgical ablation compared with catheter ablation (OR = 3.78; 95% CI, 1.55-9.21), according to the study.
QALYs and cost savings
For the other secondary endpoints, researchers observed the following:
- greater EHRA score reduction in catheter ablation compared with surgical ablation (P = .02);
- more QALYs in catheter ablation compared with surgical ablation (0.069 QALYs; P = .02); and
- lower total costs in catheter ablation compared with surgical ablation (3,534 British pounds per patient; P < .01).
“We found consistent improvements in all measures from baseline to 12 months in both groups, but the mean difference in scores at 12 months for all three measures were in favor of catheter ablation,” the researchers wrote in the European Heart Journal. “This benefit in quality of life for catheter ablation may reflect the relatively more invasive nature of surgical ablation and the higher rate of late complications.”
Reference:
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Haldar S, et al. Late-Breaking Science in Atrial Fibrillation 1. Presented at: European Society of Cardiology Congress; Aug. 29-Sept. 1, 2020 (virtual meeting).
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