Repeat Ablation Wins Out Over Antiarrhythmic Agents for Recurrent Paroxysmal

May 13, 2013

DENVER, CO — Should recurrences after a failed ablation in patients with paroxysmal atrial fibrillation (AF) be treated with antiarrhythmic drugs (AAD) or with a repeat pulmonary vein isolation (PVI) procedure? More likely second time's the charm, suggests a randomized trial showing that repeat ablation is much more likely than AAD to get rid of a recurrence[1]. Switching to AAD, it further suggested, may do little more than give the AF time to worsen.

"Progression to persistent AF was not uncommon on AAD but much less after the redo ablation," said Dr Jonathan S Steinberg (Valley Health System and Columbia University, New York, NY) when presenting the 154-patient study here at the Heart Rhythm Society (HRS) 2013 Scientific Sessions . Therefore, he said, "reablation targeting restoration of [PVI] should be strongly considered when patients respond inadequately to the initial ablation and provides superior elimination of AF compared with antiarrhythmic drugs."

There's no way to predict whether the electrical connections causing paroxysmal AF will heal after PVI ablation, according to Dr Andrea M Russo (Cooper University Hospital, Camden, NJ), who comoderated the session with Steinberg's presentation and wasn't part of the study. The guidelines don't favor either strategy for treating such recurrences, she told heartwire . Some patients choose reablation, while others decide to go with AAD, "and that's perfectly acceptable. It's more of a patient preference."

What wasn't known, she said, is "whether we should be encouraging one [approach] or the other." The current study suggests that on AAD, "not only are they going to have recurrences, they're going to progress and have a more persistent form of atrial fibrillation that [could] be more resistant down the line. So you're not going to do them much good by waiting and just treating them with antiarrhythmic drugs short term."

Out of an initial cohort of 742 patients who had a first PVI ablation for AF, the arrhythmia had recurred by the end of a three-month blanking period in 171. After exclusions (prespecified criteria included LVEF <35% and persistent AF as the recurrences), 154 were randomized to AAD or repeat PVI ablation; arrhythmia burden was monitored on implantable loop recorders.

Patients in both randomization groups had had a four- to five-year history of symptomatic AF prior to the first ablation. AAD consisted of propafenone (Rythmol, GlaxoSmithKline), flecainide, and/or sotalol (Betapace, Berlex Laboratories; Sotalex/Sotacor, Bristol-Myers Squibb) at the physicians' discretion; repeat ablation could consist only of PVI.

Outcomes at 36 Months After Start of AAD vs Reablation to Treat Recurrent AF After Initial AF Ablation

End points at 36 months AAD, n=77 (%) Reablation, n=77 (%)
AF burdena 18.8 5.6
Progression of AF burdenb 79 25
Progression to persistent AF 23 4
AF/AT-free 12 58

All differences p<0.01

AAD=antiarrhythmic drug; AF/AT=atrial fibrillation or atrial tachycardia

a. primary end point

b. by >30% compared with baseline

At the outset of the three-month blanking period, AF burden averaged about 15% in both randomization groups. It also "declined dramatically" in both groups during the blanking period. But, according to Steinberg, "as early as the three-month follow-up visit, the reablation group had a significantly lower AF burden": 1.9% vs 3.3% in the AAD group.

Thereafter, the AAD patients showed "a gradual increase in AF burden during the first 12 to 15 months, and then a much more substantial increase in AF burden for the remainder of the study until its conclusion at 36 months," he said. In contrast, the reablation group's AF burden remained low for the first 15 months and then gradually increased until the 36-month follow-up.

There were two cases of cardiac tamponade in the reablation group (3%), and 64% of patients taking AAD stopped them due to "intolerance or inefficacy," Steinberg reported; there were no strokes.

Steinberg had no disclosures. Russo discloses receiving consulting fees or honoraria from Cameron Health, Boston Scientific, Medtronic, St Jude Medical, and Biotronik; research grants from Medtronic and Cameron Health; and fellowship support from Medtronic.

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