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Optimal method and outcomes of catheter ablation of persistent atrial fibrillation: Results of the Prospective, Randomized STAR AF 2 Trial

ESC Congress 2014 - Hot Line report



By Atul Verma, (Newmarket, Canada)
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List of Authors:
A. Verma (1), C-Y. Jiang (2), TR. Betts (3), J. Chen (4), I. Deisenhofer (5), R. Mantovan (6), L. Macle (7),     C. Morillo (8), P. Sanders (9)
(1) Southlake Regional Health Centre, Cardiology, Newmarket, Canada (2) Sir Run Run Hospital of Zhejiang University, Cardiology, Hangzhou, China, People's Republic of (3) John Radcliffe Hospital, Cardiology, Oxford, United Kingdom (4) Haukeland University Hospital, Cardiology, Bergen, Norway (5) German Heart Center of Munich, Cardiology, Munich, Germany (6) Hospital Santa Maria di Ca Foncello, Treviso, Italy (7) Montreal Heart Institute, Montreal, Canada (8) McMaster University, Hamilton, Canada (9) Royal Adelaide Hospital, Adelaide, Australia


Ablation of persistent atrial fibrillation (AF) is challenging.  The optimal catheter ablation strategy for persistent AF is unknown.  Guidelines suggest that additional substrate modification in addition to pulmonary vein isolation (PVI) is required.  The STAR AF 2 (Substrate and Trigger Ablation for Reduction of AF) trial compared 3 strategies of ablation: PVI, PVI plus complex fractionated electrograms (CFE), and PVI plus linear ablation (LINES) ( NCT01203748).
Patients undergoing a first ablation procedure for drug-refractory persistent AF (defined as episodes lasting more than 7 days) were randomized 1:4:4 to each of the three strategies at 48 sites in 12 countries. For PVI (n=67), all PV antra were isolated guided by a circular mapping catheter with confirmed entrance and exit block.  For PVI+CFE (n=263), PVI was followed by AF induction and total elimination of electrograms demonstrating complex activity (or until AF terminated to sinus).  For PVI+LINES (n=259), PVI was followed by linear ablation along the left atrial roof and along the mitral isthmus with confirmation of bidirectional block.  Repeat procedures using the identical strategy as first ablation were allowed between 3-6 months.  Patients were followed at 3, 6, 9, 12 and 18 months with a visit & 48 hr Holter.  Weekly & symptomatic transtelephonic monitoring was performed for 18 months.  The primary endpoint was time to first documented AF >30 seconds after a single ablation procedure.
A total of 589 patients with persistent AF were included (79% male, age 60±9 years, LA size 45±6 mm).  Most patients (76%) were continuously in AF for >6 months pre-ablation (median duration of continuous AF 2.2 years, IQR 0.9-4.8).  At the time of ablation, 79% of patients were in spontaneous AF.  Successful PVI was achieved in 97% of all patients with no differences between groups.  For PVI+CFE, CFE were successfully mapped and ablated in 80% (11% could not be mapped because AF was non-inducible after PVI); for PVI+LINES, 74% had successful lines with bidirectional block.  Acute AF termination occurred in 45% of PVI+CFE, 22% of PVI+LINES and 8% of PVI (p<0.0001).  Procedure time was significantly shorter for PVI (167±55 min) compared to PVI+CFE (229±83 min) and PVI+LINES (223±89 min) (p<0.0001).  After 18 months, 59% of patients randomized to PVI were free from any documented AF after a single ablation compared to 48% for PVI+CFE and 44% for PVI+LINES (p=0.15).  When atrial flutter and tachycardia recurrences were counted in addition to AF, there was still no difference between the 3 arms after a single procedure.  Repeat ablation was performed in 29% of all patients with no significant difference between groups.  Complications included tamponade (0.2%), TIA (0.5%), and 1 atrio-esophageal fistula.
Catheter ablation with PVI achieves reasonable outcomes in persistent AF.  The addition of further substrate ablation with either CFE or LINES increases procedural time, but offers no additional benefit over PVI alone.


By Paulus Kirchhof, FESC (Birmingham, United Kingdom)
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Hot Line: Heart failure: devices and interventions

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.