Comparative effectiveness of catheter ablation devices in the treatment of atrial fibrillation: a network meta-analysis

Comparison of Second-Generation Cryoballoon Ablation and Quantitative Radiofrequency Ablation Guided by Ablation Index for Atrial Fibrillation

We compared the efficacy and complication rates of quantitative radiofrequency ablation guided by ablation index (RFCA-AI) with those of second-generation cryoballoon ablation (CBA-2). Consecutive patients (n = 230) with symptomatic atrial fibrillation (AF) undergoing a first ablation CBA-2 (92 patients) or RFCA-AI (138 patients) procedure were enrolled in this study. The late recurrence rate in the CBA-2 group was higher than that in the RFCA-AI group (P = .012). Subgroup analysis showed the same result in patients with paroxysmal AF (PAF) (P = .039), but no difference was found in patients with persistent AF (P = .21). The average operation duration in the CBA-2 group (85 [75-99.5] minutes) was shorter than that in the RFCA-AI group (100 [84.5-120] minutes) (P < .0001), but the average exposure time (17.36(13.87-22.49) vs 5.49(4.00-8.24) minutes) in the CBA-2 group and X-ray dose (223.25(149.15-336.95) vs 109.15(80.75-168.7) mGym) were significantly longer than those in RFCA-AI group (P < .0001). Multivariate logistic regression analysis showed that left atrial diameter (LAD), early recurrence, and methods of ablation (cryoballoon ablation) were independent risk factors for late recurrence after AF ablation. Early recurrence of AF and LAD were independent risk factors for predicting late recurrence after AF ablation.

Cost-utility of VISITAG SURPOINT in catheter ablation of atrial fibrillation

BACKGROUND

Clinical studies have demonstrated the safety, efficacy, and efficiency of VISITAG SURPOINT® (VS), which provides important lesion markers during catheter ablation (CA) of atrial fibrillation (AF). The present study evaluated the cost-effectiveness of CA with VS compared to CA without VS in AF from the publicly-funded German and Belgium healthcare perspectives.

METHODS

We constructed a two-stage cost utility model that included a decision tree to simulate clinical events, costs, and utilities during the first year after the index procedure and a Markov model to simulate transitions between health states throughout a patient's lifetime. Model inputs included published literature, a meta-analysis of randomized controlled trials AF outcomes, and publicly available administrative data on costs. Deterministic and probabilistic sensitivity analyses were conducted to determine the robustness of the model.

RESULTS

CA with VS was associated with lower per patient costs vs CA without VS (Germany: €3295 vs. €3936, Belgium: €3194 vs. €3814) and similar quality-adjusted life-years (QALYs) per patient (Germany: 5.35 vs. 5.34, Belgium: 5.68 vs. 5.67). CA with VS was the dominant ablation strategy (incremental cost-effectiveness ratios: Germany: €-52,455/QALY, Belgium: €-50,676/QALY). The model results were robust and not highly sensitive to variation to individual parameters with regard to QALYs or costs. Freedom from AF and procedure time had the greatest impact on model results, highlighting the importance of these outcomes in ablation.

CONCLUSIONS

CA with VS resulted in cost savings and QALY gains compared to CA without VS, supporting the increased adoption of VS in CA in Germany and Belgium.

Stent-based electrode for radiofrequency ablation in the rat esophagus: a preliminary study

Endoluminal radiofrequency (RF) ablation has been widely used as a safe and effective treatment for Barrett's esophagus. However, inadequate RF ablation may occur due to insufficient contact between the electrode and target tissues. Herein, a stent-based monopolar RF electrode (SE) was developed to evenly deliver RF energy to the inner wall of the rat esophagus. The optimal RF parameters were evaluated in the exposed rat esophagus. The temperature in the rat esophagus reached 70 ℃ in 89 s at 30 W, 59 s at 40 W, and 34 s at 50 W. The technical feasibility and efficacy of RF ablation using SE were evaluated based on changes in histological transformation and immunohistochemical parameters of tissues compared at immediately, 1 and 2 weeks after the procedure. The degrees of inflammatory cell infiltration, fibrotic changes, TUNEL, and HSP70 in the RF-ablated rat esophagus were significantly higher than compared with sham control (all p < 0.05). TUNEL-positive deposition gradually decreased, but HSP 70-positive deposition maintained a similar level for 2 weeks. The stent-based RF ablation was technically feasible and effective in evenly inducing thermal damages to the rat esophagus. The RF ablation system using the SE may represent a promising treatment for endoluminal malignancies.

Long-Term Cost-Effectiveness Comparison of Catheter Ablation and Antiarrhythmic Drugs in Atrial Fibrillation Treatment Using Discrete Event Simulation

OBJECTIVES

To evaluate the lifetime cost-effectiveness of 3 widely used atrial fibrillation (AF) treatments from the perspectives of Chinese healthcare system: antiarrhythmic drugs (AADs), ThermoCool SmartTouch guided by ablation index (STAI), and second-generation cryoballoon (CB2).

METHODS

A discrete event simulation (DES) model was implemented to compare the lifetime cost-effectiveness of AADs, STAI, and CB2. AF disease progression was explicitly modeled based on the Atrial Fibrillation Progression Trial clinical study results. The base-case analysis assumed that patients with paroxysmal AF (PAF) entered the model at the age of 55 years and had a CHA2DS2-VASc (Congestive heart failure, Hypertension, Age ( > 65 = 1 point, > 75 = 2 points), Diabetes, previous Stroke/transient ischemic attack (2 points)-Vascular disease (peripheral arterial disease, previous myocardial infarction, aortic atheroma), Age 65 to 74 years, and Sex category) score of 2 for males and 3 for females. Model parameter uncertainties were incorporated throughout the DES simulation with full probabilistic model parameterization.

RESULTS

The lifetime cost-effectiveness evaluations showed that patients treated with AADs gained an average of 4.98 quality-adjusted life-years (QALYs) and 9.63 life-years (LYs) at an average cost of US dollar (USD) 15 374. Patients treated with CB2 gained 5.92 QALYs and 10.74 LYs at an average cost of USD 26 811. The STAI group gained an average of 6.55 QALYs and 11.57 LYs at an average cost of USD 24 722. The incremental cost-effectiveness ratios was USD 5927 and USD 12 167 per QALY for STAI versus AADs and CB2 versus AADs, respectively. Assuming the willingness-to-pay threshold for China is USD 30 390 per QALY, both ablation treatments will be cost-effective compared with AADs for patients with PAF.

CONCLUSIONS

The DES model demonstrated that catheter ablations are more cost-effective than AADs for patients with PAF under the healthcare system in China. Among catheter ablation technologies, STAI provides better outcomes at lower costs.

Comparing efficacy and safety in catheter ablation strategies for atrial fibrillation: a network meta-analysis

BACKGROUND

There is no consensus on the most efficient catheter ablation (CA) strategy for patients with atrial fibrillation (AF). The objective of this study was to compare the efficacy and safety of different CA strategies for AF ablation through network meta-analysis (NMA).

METHODS

A systematic search of PubMed, Web of Science, and CENTRAL was performed up to October 5th, 2020. Randomized controlled trials (RCT) comparing different CA approaches were included. Efficacy was defined as arrhythmia recurrence after CA and safety as any reported complication related to the procedure during a minimum follow-up time of 6 months.

RESULTS

In total, 67 RCTs (n = 9871) comparing 19 different CA strategies were included. The risk of recurrence was significantly decreased compared to pulmonary vein isolation (PVI) alone for PVI with renal denervation (RR: 0.60, CI: 0.38-0.94), PVI with ganglia-plexi ablation (RR: 0.62, CI: 0.41-0.94), PVI with additional ablation lines (RR: 0.8, CI: 0.68-0.95) and PVI in combination with bi-atrial modification (RR: 0.32, CI: 0.11-0.88). Strategies including PVI appeared superior to non-PVI strategies such as electrogram-based approaches. No significant differences in safety were observed.

CONCLUSIONS

This NMA showed that PVI in combination with additional CA strategies, such as autonomic modulation and additional lines, seem to increase the efficacy of PVI alone. These strategies can be considered in treating patients with AF, since, additionally, no differences in safety were observed. This study provides decision-makers with comprehensive and comparative evidence about the efficacy and safety of different CA strategies.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registry number: CRD42020169494 .

Atrial fibrillation ablation with advanced radiofrequency catheter versus second-generation cryoballoon catheter

Aim: To compare cost and readmissions among atrial fibrillation (AF) patients undergoing ablation using the THERMOCOOL SMARTTOUCH™ SF (STSF) radiofrequency catheter versus the Arctic Front Advance™ (AFA) cryoballoon catheter. Patients & methods: The Premier Healthcare Database was used for the study purposes. Propensity score matching was used to match patients in the two groups. Costs and readmissions were assessed. A regression model was used for outcome assessment. Results: After propensity matching, 2767 patients were identified in each of the STSF and AFA cohorts. In the matched cohort, STSF patients had significantly lower supply costs than AFA patients. STSF patients had significantly lower 4-12-month AF-related inpatient readmissions compared with AFA patients (2.58% vs 3.99%; p = 0.0402). Costs of care summing index procedure and readmission costs were also lower for the STSF patients versus AFA patients. Conclusions: Patients who underwent AF ablation using the STSF catheter versus the AFA catheter had lower cost and AF-related readmissions.

Comparing Efficacy and Safety in Catheter Ablation Strategies for Paroxysmal Atrial Fibrillation: A Network Meta-Analysis of Randomized Controlled Trials

Although catheter ablation (CA) is an established treatment for paroxysmal atrial fibrillation (PAF), there is no consensus regarding the most efficient CA strategy. The objective of this network meta-analysis (NMA) was to compare the efficacy and safety of different CA strategies for PAF. A systematic search was performed in PubMed, Web of Science, and CENTRAL until the final search date, 5 October 2020. Randomised controlled trials (RCT) comparing different CA strategies and methods for pulmonary vein isolation (PVI) were included. Efficacy was defined as lack of arrhythmia recurrence after CA and safety as any reported complication related to the procedure during a minimum follow-up time of six months. In total, 43 RCTs comparing 11 different CA strategies involving 6701 patients were included. The risk of recurrence was significantly decreased in comparison with PVI with radiofrequency only for the following treatments: PVI with adjuvant ablation (RR: 0.79, CI: 0.65–0.97) and PVI with sympathetic modulation (RR: 0.64, CI: 0.46–0.88). However, PVI with radiofrequency was superior to non-PVI strategies (RR: 1.65, CI: 1.2–2.26). No statistically significant difference was found in safety between different CA strategies. Concerning different PVI strategies, no difference was observed either in efficacy or in safety between tested strategies. This NMA suggests that different PVI strategies are generally similar in terms of efficacy, while PVI with additional ablation or sympathetic modulation may be more effective than PVI alone. This study provides decision-makers with insights into the efficacy and safety of different CA strategies.

Second-generation cryoballoon versus contact force radiofrequency ablation for atrial fibrillation: an updated meta-analysis of evidence from randomized controlled trials

Catheter ablation has been recommended for patients with symptomatic atrial fibrillation (AF), with pulmonary vein isolation being the cornerstone of the ablation procedure. Newly developed technologies, such as cryoballoon ablation with a second-generation cryoballoon (CB2) and the contact force radiofrequency (CF-RF) ablation, have been introduced in recent years to overcome the shortcomings of the widely used RF ablation approach. However, high-quality results comparing CB2 and CF-RF remain controversial. Thus, we conducted this meta-analysis to assess the efficacy and safety between CB2 and CF-RF using evidence from randomized controlled trials (RCTs). Databases including Embase, PubMed, the Cochrane Library, and ClinicalTrials.gov were systematically searched from their date of inception to January 2021. Only RCTs that met the inclusion criteria were included for analysis. The primary outcome of interest was freedom from atrial tachyarrhythmia (AT) during follow-up. Secondary outcomes included procedure-related complications, procedure time and fluoroscopy time. Six RCTs with a total of 987 patients were finally enrolled. No significant differences were found between CB2 and CF-RF in terms of freedom from AT (relative risk [RR] = 1.03, 95% confidence interval [CI] 0.92-1.14, p = 0.616) or total procedural-related complications (RR = 1.25, 95% CI 0.69-2.27, p = 0.457). CB2 treatment was associated with a significantly higher risk of phrenic nerve palsy (PNP) than CF-RF (RR = 4.93, 95% CI 1.12-21.73, p = 0.035). The occurrences of pericardial effusion/tamponade and vascular complications were comparable between the CB2 and CF-RF treatments (RR = 0.41, p = 0.398; RR = 0.82, p = 0.632). In addition, CB2 treatment had a significantly shorter procedure time than CF-RF (weighted mean difference [WMD] = - 20.75 min, 95% CI - 25.44 ~ - 16.05 min, P < 0.001), whereas no difference was found in terms of fluoroscopy time (WMD = 4.63 min, p = 0.179). CB2 and CF-RF treatment are comparable for AF patients regarding freedom from AT and procedure-related complications. Compared to CF-RF, CB2 treatment was associated with a shorter procedure time but a higher incidence of PNP. Further large-scale studies are warranted to compare these two techniques and provide an up-to-date recommendation.

A systematic review and meta-analysis comparing second-generation cryoballoon and contact force radiofrequency ablation for initial ablation of paroxysmal and persistent atrial fibrillation

INTRODUCTION

Cryoballoon ablation (CBA) and radiofrequency ablation (RFA) are the preferred modalities for catheter ablation of atrial fibrillation (AF). Technological advances have improved procedural outcomes, warranting an updated comparison. We sought to evaluate the efficacy and safety of CBA-2nd generation (CBA-2G) in comparison to RFA-contact force (RFA-CF) in patients with AF.

METHODS

MEDLINE, Cochrane, and ClinicalTrials.gov databases were searched until 03/01/2020 for relevant studies comparing CBA-2G versus RFA-CF in patients undergoing initial catheter ablation for AF.

RESULTS

A total of 17 studies, involving 11 793 patients were included. There was no difference between the two groups in the outcomes of freedom from atrial arrhythmia (p = .67) and total procedural complications (p = .65). There was a higher incidence of phrenic nerve palsy in CBA-2G (odds ratio: 10.7; 95% confidence interval [CI]: 5.85 to 19.55; p < .001). Procedure duration was shorter (mean difference: -31.32 min; 95% CI: -40.73 to -21.92; p < .001) and fluoroscopy duration was longer (+3.21 min; 95% CI: 1.09 to 5.33; p = .003) in CBA-2G compared to RFA-CF. In the subgroup analyses of patients with persistent AF and >1 freeze lesion delivered per vein, there was no difference in freedom from atrial arrhythmia.

CONCLUSIONS

In AF patients undergoing initial ablation, CBA-2G and RFA-CF were equally efficacious. The procedure duration was shorter, but with a higher incidence of phrenic nerve palsy in CBA-2G. In patients with persistent AF, there was no difference in the efficacy between CBA-2G or RFA-CF techniques.

Systematic review and network meta-analysis of atrial fibrillation percutaneous catheter ablation technologies using randomized controlled trials

AIMS

We sought out to make comparisons between all atrial fibrillation (AF) catheter ablation technologies using randomized controlled trial data. Our comparisons were freedom from AF, procedural duration, and fluoroscopy duration.

METHODS

Searches were made of EMBASE, MEDLINE, and CENTRAL databases, and studies were selected which had cryoballoon, conventional radiofrequency (RF), multipolar RF catheters, and laser technology as an arm in the study and were identified as randomized controlled trials (RCTs). These studies were analyzed for direct comparisons using conventional meta-analysis and a combination of indirect and direct comparisons via a network meta-analysis (NMA).

RESULTS

With respect to freedom from AF both direct comparisons and NMA did not demonstrate any significant difference. However in analysis of procedural and fluoroscopy duration (minutes) for the pulmonary vein ablation catheter (PVAC), both conventional analysis and NMA revealed significantly shorter procedure times, RF vs PVAC (conventional: 61.99 [38.03-85.94], P <.00001; NMA: 54.76 [36.64-72.88], P < .0001) and fluoroscopy times, RF vs PVAC (conventional: 12.96 [6.40-19.53], P = .0001; NMA: 8.89 [3.27-14.51], P < .01). The procedural duration was also shorter for the cryoballoon with NMA, RF vs CRYO (20.56 [3.47-37.65], P = .02).

DISCUSSION

Our analysis demonstrated that while there was no difference in the efficacy of the individual catheter technologies, there are significant differences in the procedural duration for the PVAC and the cryoballoon. While they may seem an attractive solution for high-volume centers, further RCTs of next-generation technologies should be examined.