Safety and efficacy of multipolar pulmonary vein ablation catheter vs. irrigated radiofrequency ablation for paroxysmal atrial fibrillation: a randomized multicentre trial

J McCready, A W Chow, M D Lowe, O R Segal, S Ahsan, J de Bono, M Dhaliwal, C Mfuko, A Ng, E R Rowland, R J W Bradley, J Paisey, P Roberts, J M Morgan, A Sandilands, A Yue, P D Lambiase, J McCready, A W Chow, M D Lowe, O R Segal, S Ahsan, J de Bono, M Dhaliwal, C Mfuko, A Ng, E R Rowland, R J W Bradley, J Paisey, P Roberts, J M Morgan, A Sandilands, A Yue, P D Lambiase

Abstract

Aims: The current challenge in atrial fibrillation (AF) treatment is to develop effective, efficient, and safe ablation strategies. This randomized controlled trial assesses the medium-term efficacy of duty-cycled radiofrequency ablation via the circular pulmonary vein ablation catheter (PVAC) vs. conventional electro-anatomically guided wide-area circumferential ablation (WACA).

Methods and results: One hundred and eighty-eight patients (mean age 62 ± 12 years, 116 M : 72 F) with paroxysmal AF were prospectively randomized to PVAC or WACA strategies and sequentially followed for 12 months. The primary endpoint was freedom from symptomatic or documented >30 s AF off medications for 7 days at 12 months post-procedure. One hundred and eighty-three patients completed 12 m follow-up. Ninety-four patients underwent PVAC PV isolation with 372 of 376 pulmonary veins (PVs) successfully isolated and all PVs isolated in 92 WACA patients. Three WACA and no PVAC patients developed tamponade. Fifty-six percent of WACA and 60% of PVAC patients were free of AF at 12 months post-procedure (P = ns) with a significant attrition rate from 77 to 78%, respectively, at 6 months. The mean procedure (140 ± 43 vs. 167 ± 42 min, P<0.0001), fluoroscopy (35 ± 16 vs. 42 ± 20 min, P<0.05) times were significantly shorter for PVAC than for WACA. Two patients developed strokes within 72 h of the procedure in the PVAC group, one possibly related directly to PVAC ablation in a high-risk patient and none in the WACA group (P = ns). Two of the 47 patients in the PVAC group who underwent repeat ablation had sub-clinical mild PV stenoses of 25-50% and 1 WACA patient developed delayed severe PV stenosis requiring venoplasty.

Conclusion: The pulmonary vein ablation catheter is equivalent in efficacy to WACA with reduced procedural and fluoroscopy times. However, there is a risk of thrombo-embolic and pulmonary stenosis complications which needs to be addressed and prospectively monitored.

Clinicaltrialsgov identifier: NCT00678340.

Keywords: Ablation; Atrial fibrillation; Duty-cycled bipolar and unipolar radiofrequency; Electrophysiology.

© The Author 2014. Published by Oxford University Press on behalf of the European Society of Cardiology.

Figures

Figure 1
Figure 1
Example of PVAC positioning and signals recorded in LUPV pre and post ablation. (A) Pulmonary venogram (B) PVAC position in the large LUPV branch. (C) Unipolar signals recorded pre and post ablation with distal CS pacing illustrating signal attenuation and PV isolation.
Figure 2
Figure 2
CONSORT diagram illustrating patient recruitment numbers and follow-up.
Figure 3
Figure 3
Kaplan–Meier curves demonstrating freedom from AF/AT post ablation.

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Source: PubMed

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