CFAE/Spatiotemporal Dispersion Guided Ablation Versus PVI Guided Ablation in Persistent AF (CIPA)

Complex Fractionated Atrial Electrocardiograms (CFAEs) Spatiotemporal Dispersion Guided Ablation Versus Pulmonary Vein Isolation (PVI) Guided Ablation in Persistent Atrial Fibrillation, a Multicenter Randomized Trial

Objective: The purpose of this study is to compare the efficacy and safety of ablation of Atrial Fibrillation (AF) drivers marked by spatiotemporal dispersions and Complex Fractionated Atrial Electrocardiograms (CFAEs) to Pulmonary Vein Isolation (PVI) based ablation in patients with persistent AF.

Hypothesis: CFAE/spatiotemporal dispersion guided ablation will increase AF free survival compared to a PVI guided ablation.

Patient population: Patients with persistent AF will be randomized based on a 2:1 ratio into one of two study arms:

• CFAE/spatiotemporal dispersion guided ablation: CFAE mapping and ablation during AF aimed at restoring sinus rhythm during ablation.
• PVI guided ablation: wide antral pulmonary vein isolation during mapping catheter control of pulmonary vein signals

Study Overview

• Status: Recruiting
• Conditions: Chronic Atrial Fibrillation
• Intervention / Treatment: Procedure: CFAE guided ablation; Procedure: PVI guided ablation

Detailed Description

Design: A prospective, multicenter, randomized unblinded clinical study.

Objective: The purpose of this study is to compare the efficacy and safety of ablation of AF drivers marked by spatiotemporal dispersions and CFAEs guided ablation to PVI guided ablation in patients with persistent AF.

Hypothesis: CFAE/spatiotemporal dispersion guided ablation will increase AF free survival compared to a PVI guided ablation.

Enrollment: 180 patients will be enrolled in this study.

Clinical Sites: International (including non EU-countries), multicenter study.

Patient population: Patients with persistent AF (defined as atrial fibrillation which is sustained beyond 7 days but no more than one year, or lasting less than 7 days but necessitating pharmacologic or electrical cardioversion, but lasting longer than 48 hours) should be documented either on 12-lead ECG, transtelephonic monitoring (TTM), ambulatory holter monitoring (HM) or telemetry strip and a physician's note showing continuous AF. Furthermore patients who have failed at least one Anti Arrhythmic Drug (AAD) (Class I or III) as evidenced by recurrent symptomatic AF or intolerable side effects of the AAD. Eligible patients who sign the study informed consent form will be randomized based on a 2:1 ratio into one of two study arms:

• CFAE/spatiotemporal guided ablation: CFAE/spatiotemporal dispersion mapping and ablation during AF aimed at restoring sinus rhythm during ablation. Pulmonal vein isolation will be checked before and after ablation using a mapping catheter
• PVI guided ablation: wide antral pulmonary vein isolation during mapping catheter control of pulmonary vein signals

Primary Endpoint: Freedom from recorded AF or atrial flutter or atrial tachycardia recurrences (>30 seconds) without the use of AADs through 18 months follow-up, post-blanking, on either a 12 lead ECG on visits or on 24 hour holter monitoring or on symptom driven event monitoring.

CFAE/spatiotemporal dispersions procedural details: To increase the accuracy of CFAE mapping, the Pentaray mapping catheter will be used to define spatiotemporal dispersion areas of CFAEs as specific targets of ablation as described by Seitz (see also citation) as follows. Dispersion areas are defined as clusters of electrograms, either fractionated or non-fractionated, that display interelectrode time and space dispersion at a minimum of 3 adjacent bipoles such that activation spread over all the AFCL. At each bipole in a dispersion area, one or more of the following fractionated or nonfractionated electrogram morphologies can be found:

1. continuous, low-voltage fractionated electrograms ("continuously fractionated signal");
2. bursts of fractionated electrograms ("trains of fractionation");
3. fast nonfractionated electrograms (AFCL <120 ms; "rapid fires"); and
4. slow nonfractionated electrograms (AFCL >120 ms).

Multipolar electrogram dispersion and non-dispersion regions, illustrate that fractionated electrograms are found in both dispersion and non-dispersion regions.

CFAE software can be used, but CFAE ablation is not guided by the software, but based on visual judgement. Preferably a CFAE map will be made before ablation to judge the sites of most extensive CFAE sites. Baseline mapping in both atria will be performed during AF with the PentaRay multispline catheter sequentially positioned in various regions of the RA and LA. At each location, the catheter will be maintained in a stable position for a minimum of 2.5 s. The operator will look for dispersion areas (electrograms exhibiting both time and spatial dispersion). Where dispersion are found and/or the catheter is not stable for 2.5 s, acquisitions will be repeated.

Additional risks: No additional risks are anticipated for patients enrolled in this study compared to patients undergoing ablation of symptomatic AF outside of the study, because the same catheter is used as in patients outside the study, and both methods (PVI and CFAE) are part of daily practice. Although none reported in the literature so far, CFAE ablation may cause more extensive lesions than other ablation for persistent atrial fibrillation, especially in the posterior wall. This in turn may cause pericardial effusion, myocardial rupture and atrio-esophageal fistula. All of these are potentially life threatening. However, energy settings are changed according to myocardial wall size and pressure recordings, in order to prevent these complications. Furthermore, also in the group of wide antral ablation, the posterior wall is targeted, possibly resulting in the same events. For prevention of posterior wall injury, temperature monitoring in the oesofagus may be used.

Thrombus formation is a complication that can occur with any ablation technique. Thrombi may dislodge and embolize, causing a stroke, myocardial infarction or other ischemic event. Therefore, it is required that activated clotting time (ACT) is kept above 300 seconds. This should be monitored every 30 minutes, and heparin should be administered depending on the outcome. The operator is responsible for maintaining an adequate ACT.

Radiation exposure during the fluoroscopic imaging of the catheters may result in an increase in the lifetime risk of developing a fatal malignancy (0.1%) or a genetic defect in offspring (0.002%).

Potential Benefit: The direct benefit for patients undergoing ablation is the potential elimination of AF episodes. It is furthermore expected that quality of life will improve and less frequent hospitalization will be needed. Whether further morbidity as cerebral vascular events are prevented is subject to discussion. The information gained from the conduct of this study may benefit patients with AF by improving future treatment modalities.

• Study Type: Interventional
• Enrollment (Anticipated): 180
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Gery de Jong, PhD; Phone Number: ++31(0)38-4262999; Email: CIPA@diagram-zwolle.nl
• Study Contact Backup: Name: Ilona C. Kalter, Msc; Phone Number: ++31(0)38-4262999; Email: CIPA@diagram-zwolle.nl

Study Locations

• France
  • Marseille, France
    • Recruiting
    • Hopital Saint Joseph
    • Contact: Sabrina Siame
    • Principal Investigator: Julien Seitz, MD, PhD
  • Nice, France
    • Not yet recruiting
    • CHU de Nice
    • Contact: Marine Douillet, PhD
    • Principal Investigator: Guillaume Theodore, PhD
• Japan
  • Kagoshima, Japan
    • Recruiting
    • Kagoshima University
    • Contact: Naoya Oketani, MD, PhD
    • Principal Investigator: Naoya Oketani, MD, PhD
• Netherlands
  • Overijssel
    • Zwolle, Overijssel, Netherlands, 8025 AB
      • Recruiting
      • Isala
      • Contact: Karin Nijenbrinks; Phone Number: ++31 38 4244850; Email: k.nijenbrinks@diagram-zwolle.nl
      • Principal Investigator: Jaap Jan Smit, MD, PHD

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 14 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

1. Patients with persistent atrial fibrillation, defined as atrial fibrillation which is:

   1. Sustained beyond 7 days but no more than one year.
   2. Or lasting less than 7 days, but longer than 48 hours and necessitating pharmacologic or electrical cardioversion.
2. Documentation of atrial fibrillation on either a 12-lead ECG or transtelephonic monitoring (TTM), or ambulatory holter monitoring or telemetry strip and a physician's note showing continuous AF.
3. Failure of at least one AAD (Class I or III) as evidenced by recurrent symptomatic AF or intolerable side effects of the AAD.
4. Signed Patient Informed Consent Form.
5. Age 18 years or older.
6. Able and willing to comply with all pre- and follow-up testing and requirements.

Exclusion Criteria:

1. Continuous AF > 12 months (1-Year) (Longstanding Persistent AF).

1. Previous surgical or catheter ablation for atrial fibrillation.
2. Any cardiac surgery within the past 2 months (60 days) (includes PCI).
3. CABG surgery within the past 6 months (180 days).
4. Subjects that have ever undergone valvular cardiac surgical procedure (ie, ventriculotomy, atriotomy, and valve repair or replacement and presence of a prosthetic valve).

5. Cardioversion refractory (the inability to restore sinus rhythm for 30 secs or longer following electrical cardioversion).

   1. If a patient does not have documented evidence of being successfully cardioverted (NSR > 30 secs), the patient must be cardioverted prior to the ablation procedure with the study catheter.
   2. Failure to cardiovert based on the above criteria is considered a screen failure.
6. Documented LA thrombus on imaging.
7. LA size >50 mm.
8. LVEF < 30%.
9. Contraindication to anticoagulation (heparin or warfarin).
10. History of blood clotting or bleeding abnormalities.
11. Myocardial infarction within the past 2 months (60 days).
12. Documented thromboembolic event (including TIA) within the past 12 months (365 days).
13. Rheumatic Heart Disease.
14. Uncontrolled heart failure or NYHA function class III or IV.
15. Awaiting cardiac transplantation or other cardiac surgery within the next 12 months (365 days).
16. Unstable angina.
17. Acute illness or active systemic infection or sepsis.
18. AF secondary to electrolyte imbalance, thyroid disease, or reversible or non-cardiac cause.
19. Diagnosed atrial myxoma.
20. Presence of implanted ICD.
21. Significant severe pulmonary disease, (eg, restrictive pulmonary disease, constrictive or chronic obstructive pulmonary disease) or any other disease or malfunction of the lungs or respiratory system that produces chronic symptoms.
22. Significant congenital anomaly or medical problem that in the opinion of the investigator would preclude enrollment in this study.
23. Women who are pregnant (as evidenced by pregnancy test if pre- menopausal).
24. Enrollment in an investigational study evaluating another device, biologic, or drug.
25. Presence of intramural thrombus, tumor or other abnormality that precludes vascular access, or manipulation of the catheter.
26. Presence of a condition that precludes vascular access.
27. Life expectancy or other disease processes likely to limit survival to less than 12 months.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Single Group Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: CFAE guided ablation; CFAE/spatiotemporal dispersion guided ablation: CFAE mapping and ablation during AF aimed at restoring sinus rhythm during ablation.	Procedure: CFAE guided ablation; CFAE/spatiotemporal dispersions mapping and ablation during AF aimed at restoring sinus rhythm during ablation. Pulmonal vein isolation will be checked before and after ablation using a mapping catheter.
Active Comparator: PVI guided ablation; PVI guided ablation: wide antral pulmonary vein isolation during mapping catheter control of pulmonary vein signals.	Procedure: PVI guided ablation; Wide antral pulmonary vein isolation during mapping catheter control of pulmonary vein signals

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Freedom from recorded atrial fibrillation or atrial flutter or atrial tachycardia (>30 seconds) recurrences without the use of class I or III AADs	Freedom from recorded atrial fibrillation or atrial flutter or atrial tachycardia recurrences (>30 seconds) without the use of class I or III AADs through 18 months follow-up, post blanking period after ablation on either a 12 lead ECG on visits or on 24 hour holter monitoring or on symptom-driven event monitoring	18 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Freedom from recorded atrial fibrillation or atrial flutter or atrial tachycardia recurrences (>30 seconds) regardless of antiarrhythmic drugs	Freedom from recorded atrial fibrillation or atrial flutter or atrial tachycardia recurrences (>30 seconds) through 18 months follow-up on either a 12 lead ECG on visits or on 24 hour holter monitoring or on symptom-driven event monitoring, regardless of antiarrhythmic drugs	18 months
Freedom from recorded atrial fibrillation or atrial flutter recurrences (>30 seconds) regardless of antiarrhythmic drugs	Freedom from recorded atrial fibrillation or atrial flutter recurrences (>30 seconds) through 18 months follow-up on either a 12 lead ECG on visits or on 24 hour holter monitoring or on symptom-driven event monitoring, regardless of antiarrhythmic drugs	18 months
Freedom from recorded atrial fibrillation or atrial flutter or atrial tachycardia recurrences (>30 seconds), without a new AAD or a previously failed AAD at a greater than the highest ineffective historical dose	Freedom from recorded atrial fibrillation or atrial flutter or atrial tachycardia recurrences (>30 seconds) through 18 months follow-up on either a 12 lead ECG on visits or on 24 hour holter monitoring or on symptom-driven event monitoring, without a new AAD or a previously failed AAD at a greater than the highest ineffective historical dose	18 months
Freedom from recorded atrial fibrillation (>30 seconds), regardless of antiarrhythmic drugs	Freedom from recorded atrial fibrillation (>30 seconds) through 18 months follow-up on either a 12 lead ECG on visits or on 24 hour holter monitoring or on symptom-driven event monitoring, regardless of antiarrhythmic drugs	18 months
Clinical/partial success at 18 months regardless of antiarrhythmic drug use	Clinical/partial success at 18 months regardless of antiarrhythmic drug use, defined as a 75% or greater reduction in the number of AF episodes and/or the duration of AF episodes, or the % time a patient is in AF as assessed with a device capable of measuring AF burden	18 months
Time to first symptomatic, recorded AF recurrence	Time to first symptomatic, recorded AF recurrence	18 months
Time to first electrocardioversion	Time to first electrocardioversion	18 months
Symptoms associated with atrial arrhythmias	Symptoms associated with atrial arrhythmias. Measured by CCS-SAF scale (Canadian Cardiovascular Society Severity of Atrial Fibrillation Scale)	18 months
Decreased anti-arrhythmic and/or anticoagulant drug use.	Decreased anti-arrhythmic and/or anticoagulant drug use will be recorded by checking the patients medication chart	18 months
Quality of life at 6 and 12 months compared to baseline	Quality of life at 6 and 12 months compared to baseline. Measured by SF36-version 2	6 months and 12 months
Number of redo-procedures	Number of redo-procedures	18 months
Total time of fluoroscopy	Total time of fluoroscopy	1 day
Total procedure time	Total procedure time (minutes from introduction of first catheter to withdrawal of last catheter)	1 day
Total ablation time	Total ablation time	1 day
Clinical adverse events	Clinical adverse events (TIA,CVA, hemorrhage, tamponade, myocardial infarction, symptomatic pulmonary vein stenosis (> 50%), or other complications associated with AF ablation as listed in and defined by the table 6 of the 2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation2)	18 months
The combined endpoint consisting of: Mortality and Hospitalization	The combined endpoint consisting of: Mortality and Hospitalization	18 months

Collaborators and Investigators

• Sponsor: Diagram B.V.
• Collaborators: Johnson & Johnson; Biosense Webster, Inc.
• Investigators: Principal Investigator: Jaap-Jan J. Smit, MD, PhD, Isala

Publications and helpful links

General Publications

• Seitz J, Bars C, Theodore G, Beurtheret S, Lellouche N, Bremondy M, Ferracci A, Faure J, Penaranda G, Yamazaki M, Avula UM, Curel L, Siame S, Berenfeld O, Pisapia A, Kalifa J. AF Ablation Guided by Spatiotemporal Electrogram Dispersion Without Pulmonary Vein Isolation: A Wholly Patient-Tailored Approach. J Am Coll Cardiol. 2017 Jan 24;69(3):303-321. doi: 10.1016/j.jacc.2016.10.065.

Study record dates

Study Major Dates

• Study Start (Actual): October 12, 2016
• Primary Completion (Anticipated): July 1, 2025
• Study Completion (Anticipated): July 1, 2025

Study Registration Dates

• First Submitted: February 18, 2016
• First Submitted That Met QC Criteria: February 25, 2016
• First Posted (Estimate): March 2, 2016

Study Record Updates

• Last Update Posted (Actual): July 13, 2022
• Last Update Submitted That Met QC Criteria: July 11, 2022
• Last Verified: July 1, 2022

More Information

Terms related to this study

• Keywords: Atrial Fibrillation; Ablation; Pulmonary Vein Isolation; Complex Fractionated Atrial Electrocardiograms; CFAE/spatiotemporal dispersion guided ablation
• Additional Relevant MeSH Terms: Pathologic Processes; Heart Diseases; Cardiovascular Diseases; Arrhythmias, Cardiac; Atrial Fibrillation
• Other Study ID Numbers: 9227 (UKCRN); 15.09159 (Other Identifier: Ethical Committee)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: No