Randomized Controlled Trial of Surgical Versus Catheter Ablation for Paroxysmal and Early Persistent Atrial Fibrillation

Abstract

Background: Current guidelines recommend both percutaneous catheter ablation (CA) and surgical ablation in the treatment of atrial fibrillation, with different levels of evidence. No direct comparison has been made between minimally invasive thoracoscopic pulmonary vein isolation with left atrial appendage ligation (surgical MIPI) versus percutaneous CA comprising of pulmonary vein isolation as primary treatment of atrial fibrillation. We, therefore, conducted a randomized controlled trial comparing the safety and efficacy of these 2 treatment modalities. Methods: Eighty patients were enrolled in the study and underwent implantable loop recorder implantation. Twenty-eight patients did not reach randomization criteria. A total of 52 patients with symptomatic paroxysmal or early persistent atrial fibrillation were randomized, 26 to CA and 26 to surgical MIPI. The primary end point was defined as freedom of atrial tachyarrhythmias, without the use of antiarrhythmic drugs. The safety end point was freedom of complications. Results: Median age was 57 years (range, 37–75), and 78% were men. Paroxysmal atrial fibrillation was present in 74%. Follow-up duration was ≥2 years in all patients. CA was noninferior to MIPI in terms of single-procedure arrhythmia-free survival after 2 years of follow-up (56.0% versus 29.2%; HR, 0.56; 95% CI, 0.26–1.20; log-rank P =0.059). Procedure-related major adverse events occurred significantly more often in MIPI than CA (20.8% versus 0%; P =0.029). Conclusions: Percutaneous pulmonary vein isolation was noninferior to MIPI in terms of efficacy and resulted in less complications. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT00703157.

Catheter vs thoracoscopic ablation for atrial fibrillation: Meta‐analysis of randomized trials

“…Second, TA also had higher rates of adverse events particularly thoracic complications. The key clinical characteristics of eligible randomized trials include middle‐aged patients with a high prevalence of paroxysmal AF in 85%, AF duration of 5.9 years, high antiarrhythmic use in 95%, prior failed CA in approximately half, and normal mean left ventricular ejection fraction, but mildly dilated left atrial dimensions on echocardiography 7–12 . Therefore, patients with paroxysmal AF refractory to antiarrhythmic drugs and previous failed CA, but with preserved left ventricular function, are those that our findings best apply to.…”

“…Furthermore, the lower rate of repeat ablation during follow‐up (25% vs 2%) is another distinct advantage of TA. However, the high adverse event rates in up to 25% of TA even in randomized trials is important, observed across four of five studies reporting this 7,8,10,11 . In particularly, thoracic complications much higher in TA are detrimental because of their frequent need of invasive procedures, prolonging of intensive care and/or hospital stay, and potential for long‐term sequelae.…”

“…The greater efficacy seen in five of six trials for TA 7–9,11,12 may be explained by TA being more extensive with additional left atrial lines, targeting of epicardial ganglionic plexi and left atrial appendage ligation 3 . Only one study showed no difference in efficacy, in patients without previous CA, 10 suggesting TA should probably not be attempted as a first‐line therapy before CA. Furthermore, the lower rate of repeat ablation during follow‐up (25% vs 2%) is another distinct advantage of TA.…”

Catheter Ablation of Long-standing Persistent Atrial Fibrillation: a Reckless Challenge or a Way to Real Cure?

“…Therefore, highly selected patients with less amendable factors related to AF may be good candidates of AF surgery 93). However, recent randomized controlled trial failed to show superior efficacy of minimally invasive thoracoscopic PV isolation with LA appendage ligation compared to catheter ablation in spite of significantly higher complication rate 94)…”

Atrial Fibrillation: Rate, Rhythm, and Burn

“…This is reported to be the first direct comparison of a catheter-based technique to a thoracoscopic surgical technique for primary ablation of paroxysmal and recent onset persistent atrial fibrillation. 11 The majority of previous studies into surgical ablation had required patients to have had a failed catheter ablation to enter the study. They compared minimally invasive thoracoscopic pulmonary vein isolation with left atrial appendage ligation (surgical MIPI) with percutaneous catheter ablation.…”