Catheter ablation as the first line treatment for patients with long-standing persistent atrial fibrillation (LSPAF), where medications are not helping, offers similar clinical improvements to surgical ablation, according to a study led by researchers at Royal Brompton & Harefield NHS Foundation Trust.
The multi-centre study, published in the European Heart Journal and presented at the recent European Society of Cardiology conference, showed that catheter ablation provides significantly greater quality of life benefits, with fewer adverse events up to a year after the procedure.
What is the study about?
The study compared two forms of ablation; catheter ablation and thoracoscopic surgical ablation, in patients who have LSPAF and who have tried and failed drug and/or electrical cardioversion therapy.
LSPAF is a condition where atrial fibrillation (irregular and often abnormally fast heart rate) persists for more than a year and for which medication is often ineffective. This is the most challenging type of atrial fibrillation to treat and left untreated can lead to an increased risk of stroke and heart failure.
Patients with atrial fibrillation are typically offered a catheter ablation which involves putting a flexible thin tube (catheter) through a blood vessel in the groin and up into the heart where areas causing the irregular rhythm can be destroyed by radiofrequency.
More recently, thoracoscopic surgical ablation was investigated as an alternative treatment for atrial fibrillation. Small incisions are made in the chest wall and instruments are guided to the surface of the heart to block abnormal electrical signals.
So far, the data available on both procedures suggested that surgical ablation many be more effective than catheter ablation in treatment of atrial fibrillation.
Catheter ablation versus surgical ablation
For this study the researchers recruited 120 patients with LSPAF, without previous ablation, and divided them randomly into two groups; one group had surgical ablation and the other had catheter ablation.
The researchers followed up the patients for a year after their treatment and made several measurements and observations every three months. The primary objective was to establish the proportion of patients in each treatment group who were free from atrial fibrillation a year later.
The researchers also recorded the occurrence of any complications and measured patient reported quality of life. The main findings were:
- Surgical ablation was not better than catheter ablation in restoring normal heart rhythms. About 30% of patients in each group did not have atrial fibrillation at all after ablation.
- Both procedures reduced AF burden (the duration and number of AF episodes) by 75% in around 70% of patients.
- There was no significant difference in the proportion of patients in both groups who experienced serious procedure related complications during the 12 months follow up
However, the researchers did find that patients who underwent catheter ablation reported significantly greater improvements in quality of life.
Chief Investigator for the study and consultant cardiologist, Dr Tom Wong, believes that catheter ablations should remain the first line treatment option for patients with LSPAF. He said:
"Patients who suffer from continuous atrial fibrillation often do not feel well and are not able to perform their daily normal activities. This research conducted by multiple centres in the UK, brings to light that ablation, using the latest technologies, can be successful in restoring normal heart rhythm. It also demonstrates that the catheter base approach is equally effective as the surgical approach to treat this condition and to improve the quality of life of patients.”
Professor John Camm, clinical cardiologist at St George’s University of London, who is one the authors for the study, said:
“Randomisation between two very different approaches to therapy, one involving cardiac surgery, is such a difficult undertaking but has been successfully completed under the leadership of the team at Royal Brompton Hospital. This robust study, involving “state of the art technology”, clearly demonstrated that atrial fibrillation is equally well treated by the invasive electrophysiologist and the surgeon.”
Dr Shouvik Haldar, co-investigator and consultant cardiologist at the Trust, is pleased at the international recognition for the study. He said:
“This was a robustly designed and conducted clinical trial which sought to fill well known gaps in our understanding of LSPAF. We are delighted that the study has made such an impact by being selected for a late breaking clinical trial at the ESC (the largest cardiology conference in the world) and also for publication in a prestigious and high impact journal such as the European Heart Journal.
“We are grateful to all the patients who agreed to participate in the study. Their enthusiasm and commitment were vital in providing all the relevant data to answer an important clinical question. We expect this study to have a lasting impact by informing international guidelines and hence patient care worldwide.”
The research was funded by the National Institute for Health Research through the Efficacy and Mechanism Evaluation programme.
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