Hot Line 8: ALONE-AF, BEAT-PAROX-AF and CUVIA
01 Sep 2025
Hot Line ESC Congress 2025 Improving the management of atrial fibrillation (AF) was the main focus of Hot Line 8.
Professor Boyoung Joung (Yonsei University - Seoul, South Korea) described the ALONE-AF trial, which compared direct oral anticoagulation (OAC) with no OAC among 840 patients 1 year post-successful AF ablation with at least 1 risk factor for stroke (CHA2DS2-VASc ≥ 1 for males or ≥ 2 for females). At 24 months, OAC was associated with a higher risk of net adverse clinical events (stroke, systemic embolism and major bleeding) than no OAC (2.2% vs. 0.3%; absolute difference –1.9%; 95% CI –3.5 to –0.3Íž log-rank p=0.024). No significant difference was observed in ischaemic stroke or systemic embolism at 24 months between the OAC and no-OAC groups (0.8% vs. 0.3%, respectively; absolute difference –0.5%; 95% CI –1.6 to 0.6). Major bleeding occurred in 1.4% of patients with OAC and 0% without OAC. Concluding, Prof. Joung said: “In the first randomised trial to address this question, receiving no OAC treatment resulted in a lower risk of harmful events than OAC treatment. Our findings indicate that lifelong OAC is not necessary for many patients who have had successful AF ablation at least 1 year previously.”
Presented by Professor Pierre Jaïs (IHU LIRYC - Bordeaux, France), the BEAT-PAROX-AF trial compared different methods for pulmonary vein isolation (PVI): pulsed field ablation (PFA) vs. radiofrequency-based ablation (RFA) using the CLOSE protocol. Across 289 patients with symptomatic paroxysmal AF resistant to at least one antiarrhythmic drug (AAD), single-procedure success at 12 months was high and similar between the procedure types: 77.2% in the PFA group and 77.6% in the RFA group, with an adjusted difference of 0.9% (95% CI –8.2 to 10.1; p=0.84). Overall, the safety profile was excellent in both groups. Procedure-related serious adverse events including unplanned or prolonged hospitalisations occurred in 3.4% of patients in the PFA group and 7.6% in the RFA group. Total procedure duration was shorter with PFA (56 vs. 95 minutes). Professor Jaïs concluded: “Both PFA and RFA using the CLOSE protocol showed excellent and similar efficacy. Single-procedure success rates were comparable, although there appeared to be fewer complications and a shorter procedure time with PFA.”
In the final presentation, Professor Daehoon Kim (Severance Cardiovascular Hospital, Yonsei University College of Medicine - Seoul, South Korea) explained: “We have developed a personalised method that uses digital twin technology to accurately identify specific areas of an individual patient’s atrium – phase singularity (PS) points – that appear to be causing persistent AF in a simulation. In the CUVIA-PRR trial, we investigated whether combining PVI with ablation based on digital-twin guidance is more effective than PVI alone.”
In total, 304 patients with persistent AF refractory to AADs undergoing first-time AF ablation were randomised to either PVI with digital twin-guided ablation targeting stable PS points or to PVI alone. In the digital twin-guided ablation group, maps were generated before starting PVI to identify any stable PS points – these were ablated in 43.2% of patients. At 18 months after ablation, freedom from recurrent atrial arrhythmia was significantly higher with digital twin-guided ablation compared with PVI alone (77.9% vs. 59.5%; hazard ratio [HR] 0.52; 95% CI 0.33 to 0.82; log-rank p=0.004). Freedom from recurrent atrial arrhythmia without AAD use was more frequent in the digital twin-guided ablation group (45.7%) than in the PVI alone group (31.7%; HR 0.74; 95% CI 0.55 to 0.99). Mean total procedure time was comparable between the groups. Summarising the findings, Prof. Kim concluded: “Previous methods adopting a uniform approach to improve PVI success rates have not been effective and artificial intelligence-guided ablation was found to prolong procedure time. Our tailored, patient-specific ablation approach improved outcomes by precisely targeting the individual mechanisms underlying AF, without compromising safety or extending procedure time.”
