Clinical Usefulness of Computational Modeling-Guided Persistent Atrial Fibrillation Ablation: Updated Outcome of Multicenter Randomized Study

In-Soo Kim, Byounghyun Lim, Jaemin Shim, Minki Hwang, Hee Tae Yu, Tae-Hoon Kim, Jae-Sun Uhm, Sung-Hwan Kim, Boyoung Joung, Young Keun On, Seil Oh, Yong-Seog Oh, Gi-Byung Nam, Moon-Hyoung Lee, Eun Bo Shim, Young-Hoon Kim, Hui-Nam Pak, CUVIA-AF1 Investigators, In-Soo Kim, Byounghyun Lim, Jaemin Shim, Minki Hwang, Hee Tae Yu, Tae-Hoon Kim, Jae-Sun Uhm, Sung-Hwan Kim, Boyoung Joung, Young Keun On, Seil Oh, Yong-Seog Oh, Gi-Byung Nam, Moon-Hyoung Lee, Eun Bo Shim, Young-Hoon Kim, Hui-Nam Pak, CUVIA-AF1 Investigators

Abstract

Objective: Catheter ablation of persistent atrial fibrillation (AF) is still challenging, no optimal extra-pulmonary vein lesion set is known. We previously reported the clinical feasibility of computational modeling-guided AF catheter ablation.

Methods: We randomly assigned 118 patients with persistent AF (77.8% men, age 60.8 ± 9.9 years) to the computational modeling-guided ablation group (53 patients) and the empirical ablation group (55 patients) based on the operators' experience. For virtual ablation, four virtual linear and one electrogram-guided lesion sets were tested on patient heart computed tomogram-based models, and the lesion set with the fastest termination time was reported to the operator in the modeling-guided ablation group. The primary outcome was freedom from atrial tachyarrhythmias lasting longer than 30 s after a single procedure.

Results: During 31.5 ± 9.4 months, virtual ablation procedures were available in 95.2% of the patients (108/118). Clinical recurrence rate was significantly lower after a modeling-guided ablation than after an empirical ablation (20.8 vs. 40.0%, log-rank p = 0.042). Modeling-guided ablation was independently associated with a better long-term rhythm outcome of persistent AF ablation (HR = 0.29 [0.12-0.69], p = 0.005). The rhythm outcome of the modeling-guided ablation showed better trends in males, non-obese patients with a less remodeled atrium (left atrial dimension < 50 mm), ejection fraction ≥ 50%, and those without hypertension or diabetes (p < 0.01). There were no significant differences between the groups for the total procedure time (p = 0.403), ablation time (p = 0.510), and major complication rate (p = 0.900).

Conclusion: Among patients with persistent AF, the computational modeling-guided ablation was superior to the empirical catheter ablation regarding the rhythm outcome.

Clinical trial registration: This study was registered with the ClinicalTrials.gov, number NCT02171364.

Keywords: atrial fibrillation; catheter ablation; computational modeling; recurrence; virtual ablation.

Copyright © 2019 Kim, Lim, Shim, Hwang, Yu, Kim, Uhm, Kim, Joung, On, Oh, Oh, Nam, Lee, Shim, Kim and Pak.

Figures

FIGURE 1
FIGURE 1
Study flow diagram. The enrolled patients were randomly assigned to either the computational modeling-guided ablation group or the empirical ablation group. PeAF, persistent atrial fibrillation; RFCA, radiofrequency catheter ablation.
FIGURE 2
FIGURE 2
Five different protocols of virtual ablation. AL, left atrial anterior linear line; CFAE, complex fragmented atrial electrogram; CPVI, circumferential pulmonary vein isolation; LLI, left atrial left lateral isthmus line; POBI, posterior box isolation; Roof, left atrial roof line.
FIGURE 3
FIGURE 3
Kaplan–Meier curves according to patients with AAD usage. (A) Overall patients. (B) Patients with maintaining AAD use after catheter ablation. (C) Patients without maintaining AAD use after catheter ablation. AAD, antiarrhythmic drug.
FIGURE 4
FIGURE 4
Age- and sex-adjusted HR for post-RFCA clinical recurrence of AF according to subgroups (Cox proportional-hazard model regression analysis). AF, atrial fibrillation; AP diameter, antero-posterior diameter; BMI, body mass index; DM, diabetes mellitus; EF, ejection fraction; E/Em, the ratio of early transmitral flow velocity (E) to early mitral annular velocity (Em); HR, hazard ratio; HTN, hypertension.

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