Thoracoscopic ablation and left atrial appendage excision found to be superior to catheter ablation for long-term freedom from AF

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Dipak kotecha

Symptomatic atrial fibrillation (AF) patients with previous failed catheter ablation or structural changes associated with higher recurrence of AF could benefit from thoracoscopic ablation and left atrial appendage excision. The thoracoscopic approach was associated with higher initial rates of peri-procedural events, but there was no difference in long-term major adverse clinical outcomes during follow-up and less need for additional rhythm control. Dipak Kotecha (University of Birmingham, Birmingham, UK) presented the findings at the European Heart Rhythm Association Congress (EHRA; 18–20 March 2018, Barcelona, Spain) on behalf of the FAST team.

The FAST trial (Thoracoscopic vs. catheter ablation for AF) was a two country (Spain and The Netherlands) randomised controlled trial. It looked at patients with failed catheter ablation or hypertension with a dilated left atrium and patients were randomised to receive thoracoscopic ablation (n=63) or catheter ablation (n=66), which consisted of pulmonary vein isolation with optional additional lines. The one year outcomes were published in 2012, and showed higher rates of success but more perioperative complications with thoracoscopic ablation.

The follow-up study looked at all patients and they were reassessed in 2016 and 2017. All of the patients without clinical recurrence of AF underwent a further seven day ambulatory ECG. Major adverse clinical outcomes were confirmed by medical records and central government databases.

The primary rhythm endpoint was the recurrence of any atrial arrhythmia lasting more than 30 seconds during followup. The primary clinical endpoint was composite death, myocardial infarction or cerebrovascular event (transient ischaemic attach or ischaemic/haemorrhagic stroke).

The principal finding was that atrial arrhythmia recurrence was significantly lower in the thoracoscopic ablation group, 56% (34/61), compared to 87% (55/63) in the catheter ablation group (adjusted hazard ratio 0.40, 95% CI 0.25-0.64, p˂0.001). The rate of death, myocardial infarction or cerebrovascular events was similar in both groups: 15% in the thoracoscopic group and 16% in the catheter ablation group (adjusted hazard ratio 1.11, 95% CI 0.40-3.10). All cause mortality was 7% in the thoracoscopic group and 8% in the catheter ablation group (adjusted hazard ratio 0.94, 95% CI 0.18-4.94).

Recurrence of atrial arrhythmia increased sharply after around a year. The catheter ablation arm had a very progressive decline whereas it stabilised in the thoracoscopic ablation arm. At a mean follow-up period of seven years, the difference between them was statistically significant, with a p˂0.001. At final followup, antiarrhythmic drugs were used in 19% of the thoracoscopic arm compared to 39% in the catheter ablation arm. Additional ablation procedures were needed in 13% of the thoracoscopic arm and 49% of the catheter ablation arm.

The primary safety endpoint showed no difference in long-term outcomes between the two arms despite the higher initial perioperative risk in the thoracoscopic group. Ten percent of the thoracoscopic ablation arm had received pacemakers, double the 5% rate of the catheter ablation arm, but this wasn’t statistically significant (p=0.27).

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