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Effect of Catheter Ablation Using Pulmonary Vein Isolation With vs Without Posterior Left Atrial Wall Isolation on Atrial Arrhythmia Recurrence in Patients With Persistent Atrial Fibrillation: The CAPLA Randomized Clinical Trial.
Kistler, Peter M; Chieng, David; Sugumar, Hariharan; Ling, Liang-Han; Segan, Louise; Azzopardi, Sonia; Al-Kaisey, Ahmed; Parameswaran, Ramanathan; Anderson, Robert D; Hawson, Joshua; Prabhu, Sandeep; Voskoboinik, Aleksandr; Wong, Geoffrey; Morton, Joseph B; Pathik, Bhupesh; McLellan, Alex J; Lee, Geoffrey; Wong, Michael; Finch, Sue; Pathak, Rajeev K; Raja, Deep Chandh; Sterns, Laurence; Ginks, Matthew; Reid, Christopher M; Sanders, Prashanthan; Kalman, Jonathan M.
Afiliación
  • Kistler PM; The Baker Heart and Diabetes Research Institute, Melbourne, Australia.
  • Chieng D; The Alfred Hospital, Melbourne, Australia.
  • Sugumar H; University of Melbourne, Melbourne, Australia.
  • Ling LH; Cabrini Hospital, Melbourne, Australia.
  • Segan L; Monash Health, Melbourne, Australia.
  • Azzopardi S; Melbourne Private Hospital, Melbourne, Australia.
  • Al-Kaisey A; The Baker Heart and Diabetes Research Institute, Melbourne, Australia.
  • Parameswaran R; The Alfred Hospital, Melbourne, Australia.
  • Anderson RD; University of Melbourne, Melbourne, Australia.
  • Hawson J; Cabrini Hospital, Melbourne, Australia.
  • Prabhu S; The Baker Heart and Diabetes Research Institute, Melbourne, Australia.
  • Voskoboinik A; The Alfred Hospital, Melbourne, Australia.
  • Wong G; University of Melbourne, Melbourne, Australia.
  • Morton JB; Cabrini Hospital, Melbourne, Australia.
  • Pathik B; The Baker Heart and Diabetes Research Institute, Melbourne, Australia.
  • McLellan AJ; The Alfred Hospital, Melbourne, Australia.
  • Lee G; University of Melbourne, Melbourne, Australia.
  • Wong M; Cabrini Hospital, Melbourne, Australia.
  • Finch S; The Baker Heart and Diabetes Research Institute, Melbourne, Australia.
  • Pathak RK; The Alfred Hospital, Melbourne, Australia.
  • Raja DC; University of Melbourne, Melbourne, Australia.
  • Sterns L; Cabrini Hospital, Melbourne, Australia.
  • Ginks M; The Baker Heart and Diabetes Research Institute, Melbourne, Australia.
  • Reid CM; The Alfred Hospital, Melbourne, Australia.
  • Sanders P; University of Melbourne, Melbourne, Australia.
  • Kalman JM; Royal Melbourne Hospital, Melbourne, Australia.
JAMA ; 329(2): 127-135, 2023 01 10.
Article en En | MEDLINE | ID: mdl-36625809
ABSTRACT
Importance Pulmonary vein isolation (PVI) alone is less effective in patients with persistent atrial fibrillation (AF) compared with paroxysmal AF. The left atrial posterior wall may contribute to maintenance of persistent AF, and posterior wall isolation (PWI) is a common PVI adjunct. However, PWI has not been subjected to randomized comparison.

Objective:

To compare PVI with PWI vs PVI alone in patients with persistent AF undergoing first-time catheter ablation. Design, Setting, and

Participants:

Investigator initiated, multicenter, randomized clinical trial involving 11 centers in 3 countries (Australia, Canada, UK). Symptomatic patients with persistent AF were randomized 11 to either PVI with PWI or PVI alone. Patients were enrolled July 2018-March 2021, with 1-year follow-up completed March 2022.

Interventions:

The PVI with PWI group (n = 170) underwent wide antral pulmonary vein isolation followed by posterior wall isolation involving linear ablation at the roof and floor to achieve electrical isolation. The PVI-alone group (n = 168) underwent wide antral pulmonary vein isolation alone. Main Outcomes and

Measures:

Primary end point was freedom from any documented atrial arrhythmia of more than 30 seconds without antiarrhythmic medication at 12 months, after a single ablation procedure. The 23 secondary outcomes included freedom from atrial arrhythmia with/without antiarrhythmic medication after multiple procedures, freedom from symptomatic AF with/without antiarrhythmic medication after multiple procedures, AF burden between study groups at 12 months, procedural outcomes, and complications.

Results:

Among 338 patients randomized (median age, 65.6 [IQR, 13.1] years; 76.9% men), 330 (97.6%) completed the study. After 12 months, 89 patients (52.4%) assigned to PVI with PWI were free from recurrent atrial arrhythmia without antiarrhythmic medication after a single procedure, compared with 90 (53.6%) assigned to PVI alone (between-group difference, -1.2%; hazard ratio [HR], 0.99 [95% CI, 0.73-1.36]; P = .98). Of the secondary end points, 9 showed no significant difference, including freedom from atrial arrhythmia with/without antiarrhythmic medication after multiple procedures (58.2% for PVI with PWI vs 60.1% for PVI alone; HR, 1.10 [95% CI, 0.79-1.55]; P = .57), freedom from symptomatic AF with/without antiarrhythmic medication after multiple procedures (68.2% vs 72%; HR, 1.20 [95% CI, 0.80-1.78]; P = .36) or AF burden (0% [IQR, 0%-2.3%] vs 0% [IQR, 0%-2.8%], P = .47). Mean procedural times (142 [SD, 69] vs 121 [SD, 57] minutes, P < .001) and ablation times (34 [SD, 21] vs 28 [SD, 12] minutes, P < .001) were significantly shorter for PVI alone. There were 6 complications for PVI with PWI and 4 for PVI alone. Conclusions and Relevance In patients undergoing first-time catheter ablation for persistent AF, the addition of PWI to PVI alone did not significantly improve freedom from atrial arrhythmia at 12 months compared with PVI alone. These findings do not support the empirical inclusion of PWI for ablation of persistent AF. Trial Registration anzctr.org.au Identifier ACTRN12616001436460.
Asunto(s)

Texto completo: 1 Bases de datos: MEDLINE Asunto principal: Venas Pulmonares / Fibrilación Atrial / Ablación por Catéter Tipo de estudio: Clinical_trials / Etiology_studies / Prognostic_studies Límite: Aged / Female / Humans / Male / Middle aged Idioma: En Revista: JAMA Año: 2023 Tipo del documento: Article País de afiliación: Australia

Texto completo: 1 Bases de datos: MEDLINE Asunto principal: Venas Pulmonares / Fibrilación Atrial / Ablación por Catéter Tipo de estudio: Clinical_trials / Etiology_studies / Prognostic_studies Límite: Aged / Female / Humans / Male / Middle aged Idioma: En Revista: JAMA Año: 2023 Tipo del documento: Article País de afiliación: Australia