Log in to MyACC
Ablation Strategies for AF Recurrences
Quick Takes
- Left atrial appendage isolation (LAAI) using the cryoballoon did not improve freedom from atrial tachyarrhythmia/AF recurrence in patients with AF despite durably isolated pulmonary veins compared with low-voltage area ablation.
- These results do not support an empirical LAAI strategy for patients with recurrent AF after previous ablation.
Study Questions:
What is the comparative efficacy of two contemporary ablation strategies for patients with atrial fibrillation (AF) recurrences despite durably isolated pulmonary veins?
Methods:
The ASTRO AF trial investigators randomized patients with AF despite durable pulmonary vein isolation at seven centers to undergo low-voltage area ablation using three-dimensional mapping and irrigated radiofrequency current ablation (group A) or empirical left atrial appendage isolation (LAAI) using the cryoballoon followed by staged interventional left atrial appendage (LAA) closure (group B). The primary endpoint was freedom from atrial tachyarrhythmias between 91 and 365 days after index ablation. The study was powered for superiority of LAAI compared with low-voltage area.
Results:
Patients (40% women; mean age, 68.8 ± 8 years) with paroxysmal (32%) or persistent AF (68%) were randomized to undergo low-voltage area ablation (n = 79) or cryoballoon-guided LAAI (n = 82). After a planned interim analysis, enrollment was halted for futility on January 10, 2023. In the LAAI group, 77 of 82 LAAs were successfully isolated with subsequent LAA closure in 57 patients. Procedure-related complications occurred in 4 (5%) and 11 (13.5%) patients in groups A and B, respectively (p = 0.10). The median follow-up was 367 days (interquartile range, 359-378). The Kaplan-Meier point estimate for freedom from atrial tachyarrhythmias was 51.7% (confidence interval [CI], 40.9%-65.4%) for group A and 55.5% (CI, 44.4%-69.2%; p = 0.8069) for group B.
Conclusions:
The authors report that the current study did not detect superiority of cryoballoon-guided LAAI over low-voltage area ablation in patients with AF despite durable pulmonary vein isolation.
Perspective:
This prospective randomized multicenter trial reports that LAAI using the cryoballoon did not improve freedom from atrial tachyarrhythmia/AF recurrence in patients with AF despite durably isolated pulmonary veins compared with low-voltage area ablation. Of note, this study was halted prematurely for futility after randomization of 63% of the planned patient population. These results do not support an empirical LAAI strategy for patients with recurrent AF after previous ablation. Furthermore, if all pulmonary veins are found durably isolated, the optimal ablation strategy remains uncertain and needs additional research.
Clinical Topics: Arrhythmias and Clinical EP, Atrial Fibrillation/Supraventricular Arrhythmias
Keywords: Ablation, Atrial Appendage, Atrial Fibrillation, Cardiology Interventions
< Back to Listings
