Catheter ablation was associated with better arrhythmia-free survival and lower complication rates than surgical ablation in patients with paroxysmal or early-onset persistent atrial fibrillation (AFib), according to a small, randomized study published in Circulation: Arrhythmia and Electrophysiology.
This is an understudied population, as the only previous randomized trials comparing surgical versus catheter ablation came in patients who had already undergone a failed catheter ablation attempt. Senior author Arif Elvan, MD, PhD, and colleagues at Isala Heart Centre in the Netherlands excluded patients with previous ablation attempts, making this the first head-to-head, randomized comparison of surgical versus catheter approaches as a primary ablative treatment.
Twenty-six patients were randomized to each strategy, with catheter ablation showing a trend toward better arrhythmia-free survival at two years of follow-up (56 percent versus 29.2 percent). The authors classified that as proof of catheter ablation’s noninferiority for efficacy, as the trial wasn’t powered for superiority.
In addition, there were no procedure-related major adverse events in the catheter ablation (CA) group, while five patients (20.8 percent) in the surgical ablation (SA) group experienced one.
“CA is a commonly applied first-line treatment of symptomatic drug refractory paroxysmal and persistent AF, whereas surgical epicardial ablation is mostly performed in patients with previously failed CA procedures or evidence of advanced AF substrate,” Elvan and coauthors wrote. “Based on the current evidence, especially regarding the safety aspect, we would recommend not to perform first-line standalone SA of paroxysmal and early persistent AF. The future guideline committee should, therefore, consider a class III (level of evidence B) recommendation for primary standalone SA of paroxysmal AF.”
Patients were included in the study if they had either symptomatic paroxysmal AFib or persistent AFib occurring for less than three months before enrollment. They were given an implantable loop recorder for electrocardiographic monitoring, and arrhythmia-free survival was defined as the absence of an atrial tachyarrhytmia greater than 30 seconds without the use of antiarrhythmic drugs.
“Perhaps the most striking finding of this study is the poor arrhythmia-free survival of patients randomized to the surgical ablation arm,” wrote David J. Callans, MD, and Matthew C. Hyman, MD, PhD, both with the Hospital of the University of Pennsylvania, in a related editorial. “Although prior studies evaluating surgical ablation of AF boasted arrhythmia-free survival of up to 80% at 1 year, the current study found only 42% of patients were arrhythmia free at 1 year and 29.2% at 2 years.”
But considering catheter ablation was also associated with lower arrhythmia-free survival than in previous reports, the Penn researchers believe the extensive monitoring with the implantable loop recorders led to the higher detection rates.
“An evolving body of literature has clearly demonstrated that greater monitoring for arrhythmia leads to greater detection of an arrhythmia,” they wrote.
Elvan et al. said their results should be interpreted as a pilot study due to the small sample size and single-center design. Even so, Callans and Hyman said the trial is an important contribution to a field of research that remains relatively thin.
“The authors should be commended on a well-designed and successfully run randomized trial in an area where both randomized and prospective data are difficult to find,” they wrote. “Now more work must be done to develop a deeper understanding of how best and when to use these invasive therapies when managing AF. It is up to us to analyze the polygenic contributors, variable clinical presentations and modifying comorbidities to learn how best to stratify individual patients.”
Daniel joined TriMed’s Chicago editorial team in 2017 as a Cardiovascular Business writer. He previously worked as a writer for daily newspapers in North Dakota and Indiana.