Thoracoscopic vs. catheter ablation for atrial fibrillation: long-term follow-up of the FAST randomized trial

Manuel Castellá, Dipak Kotecha, Charlotte van Laar, Lisette Wintgens, Yakir Castillo, Johannes Kelder, David Aragon, María Nuñez, Elena Sandoval, Aina Casellas, Lluís Mont, Wim Jan van Boven, Lucas V A Boersma, Bart P van Putte, Manuel Castellá, Dipak Kotecha, Charlotte van Laar, Lisette Wintgens, Yakir Castillo, Johannes Kelder, David Aragon, María Nuñez, Elena Sandoval, Aina Casellas, Lluís Mont, Wim Jan van Boven, Lucas V A Boersma, Bart P van Putte

Abstract

Aims: Our objectives were to compare effectiveness and long-term prognosis after epicardial thoracoscopic atrial fibrillation (AF) ablation vs. endocardial catheter ablation, in patients with prior failed catheter ablation or high risk of failure.

Methods and results: Patients were randomized to thoracoscopic or catheter ablation, consisting of pulmonary vein isolation with optional additional lines (2007-2010). Patients were reassessed in 2016/2017, and those without documented AF recurrence underwent 7-day ambulatory electrocardiography. The primary rhythm outcome was recurrence of any atrial arrhythmia lasting >30 s. The primary clinical endpoint was a composite of death, myocardial infarction, or cerebrovascular event, analysed with adjusted Cox proportional hazard ratios (HRs). One hundred and 24 patients were randomized with 34% persistent AF and mean age 56 years. Arrhythmia recurrence was common at mean follow-up of 7.0 years, but substantially lower with thoracoscopic ablation: 34/61 (56%) compared with 55/63 (87%) with catheter ablation [adjusted HR 0.40, 95% confidence interval (CI) 0.25-0.64; P < 0.001]. Additional ablation procedures were performed in 8 patients (13%) compared with 31 (49%), respectively (P < 0.001). Eleven patients (19%) were on anti-arrhythmic drugs at end of follow-up with thoracoscopy vs. 24 (39%) with catheter ablation (P = 0.012). There was no difference in the composite clinical outcome: 9 patients (15%) in the thoracoscopy arm vs. 10 patients (16%) with catheter ablation (HR 1.11, 95% CI 0.40-3.10; P = 0.84). Pacemaker implantation was required in 6 patients (10%) undergoing thoracoscopy and 3 (5%) in the catheter group (P = 0.27).

Conclusion: Thoracoscopic AF ablation demonstrated more consistent maintenance of sinus rhythm than catheter ablation, with similar long-term clinical event rates.

Keywords: Ablation; Atrial fibrillation; Catheter; Mortality; Rhythm; Surgery; Thoracoscopy.

© The Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Cardiology.

Figures

Figure 1
Figure 1
Study flowchart. *For rhythm outcome in thoracoscopic arm, n = 3 censored at 1 year (n = 2 unwilling to have 7-day ECG on follow-up due to lack of AF or symptoms and n = 1 moved abroad). AF, atrial fibrillation; ECG, electrocardiogram.
Figure 2
Figure 2
Kaplan–Meier curves for the primary rhythm and clinical endpoints. (A) Time to atrial arrhythmia recurrence after the blanking period. (B) Time to first event—death, MI, or cerebrovascular event (transient ischaemic attack, ischaemic, or haemorrhagic stroke). MI, myocardial infarction.
Figure 3
Figure 3
Thoracoscopic vs. catheter ablation: arrhythmia recurrence by subgroup. Numbers in brackets are the number of patients with recurrence/total number in that subgroup. AAD, antiarrhythmic drugs; AF, atrial fibrillation.
Figure 4
Figure 4
Meta-analysis of incident rate ratios for arrhythmia recurrence in prospective randomized trials. Summary data for the three randomized controlled trials of thoracoscopic vs. catheter ablation for AF. Note that each study had different inclusion criteria, ablation strategies, and use of antiarrhythmic drug therapy during follow-up. The incidence rate ratio is the rate of arrhythmia recurrence weighted by person-months of follow-up comparing thoracoscopic with catheter ablation. Cochrane risk of bias domains are (from left to right): sequence generation, allocation concealment, blinding, incomplete outcome data, selective reporting and other threats to validity; scored as low risk (L), unclear risk (U), or high risk (H) of bias. AF, atrial fibrillation; CI, confidence interval; I2, heterogeneity.

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