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Yesterday, the first late-breaking trials session of EHRA 2019 revealed some interesting new insights into the treatment of atrial fibrillation (AF).
“Advances in technologies used for PVI should enable us to re- evaluate some of our long-held views on ablation for AF,” said
Professor Prapa Kanagaratnam of Imperial College London, London, UK.
He continued, “The AVATAR-AF trial investigated the feasibility of reducing resource utilisation in AF ablation without xompromising outcomes. A streamlined AF ablation approach using a cryoballoon without pulmonary vein mapping, overnight hospitalisation or routine rhythm monitoring, the so-called ‘AVATAR’ protocol, was tested in 321 patients across 13 UK centres.”
Prof. Kanagaratnam explained how symptomatic patients with paroxysmal AF were randomised to one of three arms: the streamlined AVATAR-protocol ablation (n=110), optimisation of anti-arrhythmic drug therapy (n=103) or conventional AF ablation with pulmonary vein mapping after cryoablation and overnight hospitalisation (n=108). Patients underwent a 12-week treatment pathway that included catheter ablation and adjustment of medication.
Following this, patients were discharged from hospital-based specialist care. The primary endpoint was time to any hospital episode (including outpatient consultation) related to treatment for atrial arrhythmia.
Describing the results, Prof. Kanagaratnam said, “At 1 year after the first intervention, 21% of patients returned for hospital- based treatment for atrial arrhythmia in the AVATAR arm, whereas a much larger proportion, 76%, met the primary endpoint when receiving only drug therapy and the difference between the groups was highly significant. However, there was no significant difference between the AVATAR protocol group and the conventional cryoballoon arm (21% vs 18%).”
Prof. Kanagaratnam commented, “We found that the streamlined cryo-ablation approach was superior to drug therapy. This is the first time this comparison between catheter ablation and drug therapy has been made for a symptom-based outcome. These findings validate the ESC Consensus Statement recommendations for ‘catheter ablation for symptomatic patients with paroxysmal AF.’ The AVATAR- AF study also supports the argument for proceeding directly to catheter ablation without trying Class I/III antiarrhythmic agents. The secondary objective of the study was the comparison with conventional cryoballoon ablation, and despite following standard practice of electrical mapping and confirmation of pulmonary vein isolation, this was not superior to the AVATAR approach.” Prof Kanagaratnam concluded that, “the results may have wide-ranging implications and on how we deliver AF therapy and manage resources in the face of growing demand.”
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