Direct-to-catheter ablation versus second line catheter ablation for persistent atrial fibrillation: Effect on arrhythmia recurrence, AF burden, early left atrium remodeling and quality of life.

Catheter ablation has obtained class 1 indication in ablation of young, healthy patients with symptomatic paroxysmal atrial fibrillation (AF). Anti-arrhythmic drugs (AADs) remain first-line therapy before ablating persistent AF (PersAF). We sought to evaluate the efficacy of a direct-to-catheter ablation approach against catheter ablation post AADs in PersAF. In this DECAAF II subanalysis, patients were stratified into two subgroups: 'Direct-to-catheter' group comprising patients who had not received AADs prior to ablation, and'second-line ablation' group, comprising patients who had been on any AAD therapy at any time before ablation. Patients were followed over 18 months. The primary outcome was AF recurrence. Secondary outcomes included AF burden, quality of life (QoL) that assessed by the AFSS and SF-36 scores, and changes in the left atrial volume index (LAVI) assessed by LGE-MRI scans. The analysis included 815 patients, with 279 classified as'direct-to-catheter' group and 536 classified as'Second-line ablation' group. The primary outcome was similar between both groups (44.8% vs 44.4%, p > 0.05), as was AF burden (20% vs 16%, p > 0.05). Early remodeling, reflected by LAVI reduction, was similar between the groups (9.1 [1.6-18.0] in the second-line ablation group and 9.5 [2.5-19.7] in the direct-to-catheter group, p > 0.05). QoL pre/post ablation was also similar (p > 0.05). On multivariate analysis, history of AAD was not predictive of AF recurrence(p > 0.05). Prior AAD therapy demonstrated minimal impact on atrial remodeling and QoL improvement, in addition to limited benefit on AF recurrence and burden post-ablation in patients with PersAF. Additional studies are warranted to explore the efficacy of catheter ablation as a first-line therapy in PersAF.

Younes H ，Ademi B ，Tsakiris E ，Feng H ，Pandey AC ，Mekhael M ，Noujaim C ，Lim C ，Dagher L ，Hajjar AHE ，Bidaoui G ，Bsoul M ，Assaf A ，Rao S ，Mahnkopf C ，Shamaileh G ，Kreidieh O ，Hassan A ，Liu Y ，Jia Y ，Polo FT ，Marrouche NF ，Donnellan E ... -  《-》

Early Remodeling of the Left Atrium Following Catheter Ablation of Atrial Fibrillation: Insights From DECAAFII.

Assaf AY ，Noujaim C ，Mekhael M ，Younes H ，Chouman N ，Dhore-Patil A ，Donnellan E ，Feng H ，Shan B ，Kholmovski EG ，Marrouche NF ，Kreidieh O ... -  《-》

Influence of atrial fibrillation type on outcomes of ablation vs. drug therapy: results from CABANA.

Influence of atrial fibrillation (AF) type on outcomes seen with catheter ablation vs. drug therapy is incompletely understood. This study assesses the impact of AF type on treatment outcomes in the Catheter Ablation vs. Antiarrhythmic Drug Therapy for Atrial Fibrillation Trial (CABANA). CABANA randomized 2204 patients ≥65 years old or <65 with at least one risk factor for stroke to catheter ablation or drug therapy. Of these, 946 (42.9%) had paroxysmal AF (PAF), 1042 (47.3%) had persistent AF (PersAF), and 215 (9.8%) had long-standing persistent AF (LSPAF) at baseline. The primary endpoint was a composite of death, disabling stroke, serious bleeding, or cardiac arrest. Symptoms were measured with the Mayo AF-Specific Symptom Inventory (MAFSI), and quality of life was measured with the Atrial Fibrillation Effect on Quality of Life (AFEQT). Comparisons are reported by intention to treat. Compared with drug therapy alone, catheter ablation produced a 19% relative risk reduction in the primary endpoint for PAF {adjusted hazard ratio [aHR]: 0.81 [95% confidence interval (CI): 0.50, 1.30]}, and a 17% relative reduction for PersAF (aHR: 0.83, 95% CI: 0.56, 1.22). For LSPAF, the ablation relative effect was a 7% reduction (aHR: 0.93, 95% CI: 0.36, 2.44). Ablation was more effective than drug therapy at reducing first AF recurrence in all AF types: by 51% for PAF (aHR: 0.49, 95% CI: 0.39, 0.62), by 47% for PersAF (aHR: 0.53, 95% CI: 0.43,0.65), and by 36% for LSPAF (aHR 0.64, 95% CI 0.41,1.00). Ablation was associated with greater improvement in symptoms, with the mean difference between groups in the MAFSI frequency score favouring ablation over 5 years of follow-up in all subgroups: PAF had a clinically significant -1.9-point difference (95% CI: -1.2 to -2.6); PersAF a -0.9 difference (95% CI: -0.2 to -1.6); LSPAF a clinically significant difference of -1.6 points (95% CI: -0.1 to -3.1). Ablation was also associated with greater improvement in quality of life in all subgroups, with the AFEQT overall score in PAF patients showing a clinically significant 5.3-point improvement (95% CI: 3.3 to 7.3) over drug therapy alone over 5 years of follow-up, PersAF a 1.7-point difference (95% CI: 0.0 to 3.7), and LSPAF a 3.1-point difference (95% CI: -1.6 to 7.8). Prognostic treatment effects of catheter ablation compared with drug therapy on the primary and major secondary clinical endpoints did not differ consequentially by AF subtype. With regard to decreases in AF recurrence and improving quality of life, ablation was more effective than drug therapy in all three AF type subgroups. NCT00911508.

Monahan KH ，Bunch TJ ，Mark DB ，Poole JE ，Bahnson TD ，Al-Khalidi HR ，Silverstein AP ，Daniels MR ，Lee KL ，Packer DL ，CABANA Investigators ... -  《-》

Sex-specific outcomes and left atrial remodeling following catheter ablation of persistent atrial fibrillation: results from the DECAAF II trial.

Catheter ablation is recognized as an effective treatment for atrial fibrillation (AF). Despite its effectiveness, significant sex-specific differences have been observed, which influence the outcomes of the procedure. This study explores these differences in a cohort of patients with persistent AF. We aim to assess sex differences in baseline characteristics, symptoms, quality of life, imaging findings, and response to catheter ablation in patients with persistent AF. This post hoc analysis of the DECAAF II trial evaluated 815 patients (161 females, 646 males). Between July 2016 and January 2020, participants were enrolled and randomly assigned to receive either personalized ablation targeting left atrial (LA) fibrosis using DE-MRI in conjunction with pulmonary vein isolation (PVI) or PVI alone. In this analysis, we aimed to compare female and male patients in the full cohort in terms of demographics, risk factors, medications, and outcomes such as AF recurrence, AF burden, LA volume reduction assessed by LGE-MRI before and 3 months after ablation, quality of life assessed by the SF-36 score, and safety outcomes. Statistical methods included t-tests, chi-square, and multivariable Cox regression. Females were generally older with more comorbidities and experienced higher rates of arrhythmia recurrence post-ablation (53.3% vs. 40.2%, p < 0.01). Females also showed a higher AF burden (21% vs. 16%, p < 0.01) and a smaller reduction in left atrial volume indexed to body surface area post-ablation compared to male patients (8.36 (9.94) vs 11.35 (13.12), p-value 0.019). Quality of life scores were significantly worse in females both pre- and post-ablation (54 vs. 66 pre-ablation; 69 vs. 81 post-ablation, both p < 0.01), despite similar improvements across sexes. Safety outcomes and procedural parameters were similar between male and female patients. The study highlights significant differences in the outcomes of catheter ablation of persistent AF between sexes, with female patients showing worse quality of life, higher recurrence of AF and AF burden after ablation, and worse LA remodeling.

Younes H ，Sohns C ，Akoum N ，Feng H ，Tsakiris E ，Hajjar AHE ，Donnellan E ，Pandey AC ，Lim C ，Bidaoui G ，Mekhael M ，Noujeim C ，Chouman N ，Assaf A ，Shamaileh G ，Polo FT ，Bsoul M ，Dagher L ，Kreidieh O ，Rao S ，Sommer P ，Forkmann M ，Brachmann J ，Marrouche N ，Mahnkopf C ... -  《-》

Ablation for atrial fibrillation: an evidence-based analysis.

Medical Advisory Secretariat 《-》