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Cappato R, Mark DB, Silverstein AP, Noseworthy PA, Bonitta G, Poole JE, Piccini JP, Bahnson TD, Daniels MR, Al-Khalidi HR, Lee KL, Packer DL. Regional differences in outcomes with ablation versus drug therapy for atrial fibrillation: Results from the CABANA trial. Am Heart J 2024; 270:103-116. [PMID: 38307365 PMCID: PMC11070931 DOI: 10.1016/j.ahj.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 01/18/2024] [Accepted: 01/27/2024] [Indexed: 02/04/2024]
Abstract
BACKGROUND The finding of unexpected variations in treatment benefits by geographic region in international clinical trials raises complex questions about the interpretation and generalizability of trial findings. We observed such geographical variations in outcome and in the effectiveness of atrial fibrillation (AF) ablation versus drug therapy in the Catheter Ablation vs Antiarrhythmic Drug Therapy for Atrial Fibrillation (CABANA) trial. This paper describes these differences and investigates potential causes. METHODS The examination of treatment effects by geographic region was a prespecified analysis. CABANA enrolled patients from 10 countries, with 1,285 patients at 85 North American (NA) sites and 919 at 41 non-NA sites. The primary endpoint was a composite of death, disabling stroke, serious bleeding, or cardiac arrest. Death and first atrial fibrillation recurrence were secondary endpoints. RESULTS At least 1 primary endpoint event occurred in 157 patients (12.2%) from NA and 33 (3.6%) from non-NA sites over a median 54.9 and 40.5 months of follow-up, respectively (NA/non-NA adjusted hazard ratio (HR) 2.18, 95% confidence interval (CI) 1.48-3.21, P < .001). In NA patients, 78 events occurred in the ablation and 79 in the drug arm, (HR 0.91, 95% CI 0.66, 1.24) while 11 and 22 events occurred in non-NA patients (HR 0.51, 95% CI 0.25,1.05, interaction P = .154). Death occurred in 53 ablation and 51 drug therapy patients in the NA group (HR 0.96, 95% CI 0.65,1.42) and in 5 ablation and 16 drug therapy patients in the non-NA group (HR 0.32, 95% CI 0.12,0.86, interaction P = .044). Adjusting for baseline regional differences or prognostic risk variables did not account for the regional differences in treatment effects. Atrial fibrillation recurrence was reduced by ablation in both regions (NA: HR 0.54, 95% CI 0.46, 0.63; non-NA: HR 0.44, 95% CI 0.30, 0.64, interaction P = .322). CONCLUSIONS In CABANA, primary outcome events occurred significantly more often in the NA group but assignment to ablation significantly reduced all-cause mortality in the non-NA group only. These differences were not explained by regional variations in procedure effectiveness, safety, or patient characteristics. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0091150; https://clinicaltrials.gov/study/NCT00911508.
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Affiliation(s)
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University, Durham, NC.
| | | | | | - Gianluca Bonitta
- L'altra Statistica Consultancy and Training, Biostatistics Office, Roma, Italy
| | | | | | | | | | | | - Kerry L Lee
- Duke Clinical Research Institute, Duke University, Durham, NC
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Verma A, Haines DE, Boersma LV, Sood N, Natale A, Marchlinski FE, Calkins H, Sanders P, Packer DL, Kuck KH, Hindricks G, Tada H, Hoyt RH, Irwin JM, Andrade J, Cerkvenik J, Selma J, DeLurgio DB. Influence of monitoring and atrial arrhythmia burden on quality of life and health care utilization in patients undergoing pulsed field ablation: A secondary analysis of the PULSED AF trial. Heart Rhythm 2023; 20:1238-1245. [PMID: 37211146 DOI: 10.1016/j.hrthm.2023.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 05/05/2023] [Accepted: 05/12/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND Freedom from atrial arrhythmia (AA) recurrence ≥30 seconds after pulsed field ablation (PFA) in patients with atrial fibrillation (AF) was reported in PULSED AF (Pulsed Field Ablation to Irreversibly Electroporate Tissue and Treat AF; ClinialTrials.gov Identifier: NCT04198701). AA burden may be a more clinically meaningful endpoint. OBJECTIVE The purpose of this study was to determine the influence of monitoring strategies on AA detection and AA burden association with quality of life (QoL) and health care utilization (HCU) after PFA. METHODS Patients underwent 24-hour Holter monitoring at 6 and 12 months and weekly, and symptomatic transtelephonic monitoring (TTM). AA burden post-blanking was calculated as the greater of (1) percentage of AA on total Holter time; or (2) percentage of weeks with ≥1 TTM with AA out of all weeks with ≥1 TTM. RESULTS Freedom from all AAs varied by >20% when differing monitoring strategies were used. PFA resulted in zero burden in 69.4% of paroxysmal atrial fibrillation (PAF) and 62.2% of persistent atrial fibrillation (PsAF) patients. Median burden was low (<9%). Most PAF and PsAF patients had ≤1 week of AA detection on TTM (82.6% and 75.4%) and <30 minutes of AA per day of Holter monitoring (96.5% and 89.6%), respectively. Only PAF patients with <10% AA burden averaged a clinically meaningful (>19 point) QoL improvement. PsAF patients experienced clinically meaningful QoL improvements irrespective of burden. Repeat ablations and cardioversions significantly increased with higher AA burden (P <.01). CONCLUSION The ≥30-second AA endpoint is dependent on the monitoring protocol used. PFA resulted in low AA burden for most patients, which was associated with clinically relevant improvement in QoL and reduced AA-related HCU.
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Affiliation(s)
- Atul Verma
- McGill University Health Centre, Montreal, Quebec, Canada.
| | | | - Lucas V Boersma
- St. Antonius Hospital, Nieuwegein and Amsterdam UMC, The Netherlands
| | - Nitesh Sood
- Southcoast Health Center, Fall River, Massachusetts
| | | | | | | | | | | | | | | | | | | | | | - Jason Andrade
- Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | | | - David B DeLurgio
- Emory Heart & Vascular Center at Saint Joseph's, Atlanta, Georgia
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3
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Simard T, Sarma D, Miranda WR, Jain CC, Anderson JH, Collins JD, El Sabbagh A, Jhand A, Peikert T, Reeder GS, Munger TM, Packer DL, Holmes DR. Pathogenesis, Evaluation, and Management of Pulmonary Vein Stenosis: JACC Review Topic of the Week. J Am Coll Cardiol 2023; 81:2361-2373. [PMID: 37316116 DOI: 10.1016/j.jacc.2023.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 04/06/2023] [Indexed: 06/16/2023]
Abstract
Pulmonary vein stenosis (PVS) can arise from several etiologies, including congenital, acquired, and iatrogenic sources. PVS presents insidiously, leading to significant delays in diagnosis. A high index of suspicion and dedicated noninvasive evaluation are key to diagnosis. Once diagnosed, both noninvasive and invasive evaluation may afford further insights into the relative contribution of PVS to symptoms. Treatment of underlying reversible pathologies coupled with transcatheter balloon angioplasty and stenting for persistent severe stenoses are established approaches. Ongoing refinements in diagnostic modalities, interventional approaches, postintervention monitoring, and medical therapies hold promise to further improve patient outcomes.
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Affiliation(s)
- Trevor Simard
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA. https://twitter.com/tjsimard
| | - Dhruv Sarma
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA. https://twitter.com/SarmaDhruv
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - C Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jason H Anderson
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Abdallah El Sabbagh
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Aravdeep Jhand
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Tobias Peikert
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Guy S Reeder
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Thomas M Munger
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Douglas L Packer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - David R Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
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Imamura K, Deisher AJ, Dickow J, Rettmann ME, Yasin OZ, Pepin MD, Hohmann S, Konishi H, Suzuki A, Newman LK, Sun X, Kruse JJ, Merrell KW, Herman MG, Foote RL, Packer DL. Early Impact of Proton Beam Therapy on Electrophysiological Characteristics in a Porcine Model. Circ Arrhythm Electrophysiol 2023:e011179. [PMID: 37183678 DOI: 10.1161/circep.122.011179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
BACKGROUND Particle therapy is a noninvasive, catheter-free modality for cardiac ablation. We previously demonstrated the efficacy for creating ablation lesions in the porcine heart. Despite several earlier studies, the exact mechanism of early biophysical effects of proton and photon beam delivery on the myocardium remain incompletely resolved. METHODS Ten normal and 9 infarcted in situ porcine hearts received proton beam irradiation (40 Gy) delivered to the left ventricular myocardium with follow-up for 8 weeks. High-resolution electroanatomical mapping of the left ventricular was performed at baseline and follow-up. Bipolar voltage amplitude, conduction velocity, and connexin-43 were determined within the irradiated and nonirradiated areas. RESULTS The irradiated area in normal hearts showed a significant reduction of bipolar voltage amplitude (10.1±4.9 mV versus 5.7±3.2, P<0.0001) and conduction velocity (85±26 versus 55±13 cm/s, P=0.03) beginning at 4 weeks after irradiation. In infarcted myocardium after irradiation, bipolar voltage amplitude of the infarct scar (2.0±2.9 versus 0.8±0.7 mV, P=0.008) was significantly reduced as well as the conduction velocity in the infarcted heart (43.7±15.7 versus 26.3±11.4 cm/s, P=0.02). There were no significant changes in bipolar voltage amplitude and conduction velocity in nonirradiated myocardium. Myocytolysis, capillary hyperplasia, and dilation were seen in the irradiated myocardium 8 weeks after irradiation. Active caspase-3 and reduction of connexin-43 expression began in irradiated myocardium 1 week after irradiation and decreased over 8 weeks. CONCLUSIONS Irradiation of the myocardium with proton beams reduce connexin-43 expression, conduction velocity, and bipolar conducted electrogram amplitude in a large porcine model. The changes in biomarkers preceded electrophysiological changes after proton beam therapy.
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Affiliation(s)
- Kimitake Imamura
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic/St. Mary's Campus, Mayo Clinic, Rochester, MN. (K.I., J.D., M.E.R., O.Z.Y., S.H., H.K., A.S., L.K.N., D.L.P.)
| | - Amanda J Deisher
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN. (A.J.D., M.D.P., J.J.K., K.W.M., M.G.H., R.L.F.)
| | - Jannis Dickow
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic/St. Mary's Campus, Mayo Clinic, Rochester, MN. (K.I., J.D., M.E.R., O.Z.Y., S.H., H.K., A.S., L.K.N., D.L.P.)
| | - Maryam E Rettmann
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic/St. Mary's Campus, Mayo Clinic, Rochester, MN. (K.I., J.D., M.E.R., O.Z.Y., S.H., H.K., A.S., L.K.N., D.L.P.)
| | - Omar Z Yasin
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic/St. Mary's Campus, Mayo Clinic, Rochester, MN. (K.I., J.D., M.E.R., O.Z.Y., S.H., H.K., A.S., L.K.N., D.L.P.)
| | - Mark D Pepin
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN. (A.J.D., M.D.P., J.J.K., K.W.M., M.G.H., R.L.F.)
| | - Stephan Hohmann
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic/St. Mary's Campus, Mayo Clinic, Rochester, MN. (K.I., J.D., M.E.R., O.Z.Y., S.H., H.K., A.S., L.K.N., D.L.P.)
| | - Hiroki Konishi
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic/St. Mary's Campus, Mayo Clinic, Rochester, MN. (K.I., J.D., M.E.R., O.Z.Y., S.H., H.K., A.S., L.K.N., D.L.P.)
| | - Atsushi Suzuki
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic/St. Mary's Campus, Mayo Clinic, Rochester, MN. (K.I., J.D., M.E.R., O.Z.Y., S.H., H.K., A.S., L.K.N., D.L.P.)
| | - Laura K Newman
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic/St. Mary's Campus, Mayo Clinic, Rochester, MN. (K.I., J.D., M.E.R., O.Z.Y., S.H., H.K., A.S., L.K.N., D.L.P.)
| | - Xiaojing Sun
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN. (X.S.)
| | - Jon J Kruse
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN. (A.J.D., M.D.P., J.J.K., K.W.M., M.G.H., R.L.F.)
| | - Kenneth W Merrell
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN. (A.J.D., M.D.P., J.J.K., K.W.M., M.G.H., R.L.F.)
| | - Michael G Herman
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN. (A.J.D., M.D.P., J.J.K., K.W.M., M.G.H., R.L.F.)
| | - Robert L Foote
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN. (A.J.D., M.D.P., J.J.K., K.W.M., M.G.H., R.L.F.)
| | - Douglas L Packer
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic/St. Mary's Campus, Mayo Clinic, Rochester, MN. (K.I., J.D., M.E.R., O.Z.Y., S.H., H.K., A.S., L.K.N., D.L.P.)
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Verma A, Haines DE, Boersma LV, Sood N, Natale A, Marchlinski FE, Calkins H, Sanders P, Packer DL, Kuck KH, Hindricks G, Onal B, Cerkvenik J, Tada H, DeLurgio DB. Pulsed Field Ablation for the Treatment of Atrial Fibrillation: PULSED AF Pivotal Trial. Circulation 2023; 147:1422-1432. [PMID: 36877118 PMCID: PMC10158608 DOI: 10.1161/circulationaha.123.063988] [Citation(s) in RCA: 93] [Impact Index Per Article: 93.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 02/07/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND Pulsed field ablation uses electrical pulses to cause nonthermal irreversible electroporation and induce cardiac cell death. Pulsed field ablation may have effectiveness comparable to traditional catheter ablation while preventing thermally mediated complications. METHODS The PULSED AF pivotal study (Pulsed Field Ablation to Irreversibly Electroporate Tissue and Treat AF) was a prospective, global, multicenter, nonrandomized, paired single-arm study in which patients with paroxysmal (n=150) or persistent (n=150) symptomatic atrial fibrillation (AF) refractory to class I or III antiarrhythmic drugs were treated with pulsed field ablation. All patients were monitored for 1 year using weekly and symptomatic transtelephonic monitoring; 3-, 6-, and 12-month ECGs; and 6- and 12-month 24-hour Holter monitoring. The primary effectiveness end point was freedom from a composite of acute procedural failure, arrhythmia recurrence, or antiarrhythmic escalation through 12 months, excluding a 3-month blanking period to allow recovery from the procedure. The primary safety end point was freedom from a composite of serious procedure- and device-related adverse events. Kaplan-Meier methods were used to evaluate the primary end points. RESULTS Pulsed field ablation was shown to be effective at 1 year in 66.2% (95% CI, 57.9 to 73.2) of patients with paroxysmal AF and 55.1% (95% CI, 46.7 to 62.7) of patients with persistent AF. The primary safety end point occurred in 1 patient (0.7%; 95% CI, 0.1 to 4.6) in both the paroxysmal and persistent AF cohorts. CONCLUSIONS PULSED AF demonstrated a low rate of primary safety adverse events (0.7%) and provided effectiveness consistent with established ablation technologies using a novel irreversible electroporation energy to treat patients with AF. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT04198701.
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Affiliation(s)
- Atul Verma
- McGill University Health Centre, Montreal, Canada (A.V.)
| | | | - Lucas V. Boersma
- St. Antonius Hospital, Nieuwegein and Amsterdam UMC, the Netherlands (L.V.B.)
| | - Nitesh Sood
- Southcoast Health Center, Fall River, MA (N.S.)
| | | | | | | | | | | | | | | | - Birce Onal
- Medtronic, Inc, Minneapolis, MN (B.O., J.C.)
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Agasthi P, Sridhara S, Rattanawong P, Venepally N, Chao CJ, Ashraf H, Pujari SH, Allam M, Almader-Douglas D, Alla Y, Kumar A, Mookadam F, Packer DL, Holmes DR, Hagler DJ, Fortuin FD, Arsanjani R. Safety and efficacy of balloon angioplasty compared to stent-based-strategies with pulmonary vein stenosis: A systematic review and meta-analysis. World J Cardiol 2023; 15:64-75. [PMID: 36911751 PMCID: PMC9993931 DOI: 10.4330/wjc.v15.i2.64] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 11/17/2022] [Accepted: 02/08/2023] [Indexed: 02/21/2023] Open
Abstract
BACKGROUND Pulmonary vein stenosis (PVS) is an uncommon but known cause of morbidity and mortality in adults and children and can be managed with percutaneous re-vascularization strategies of pulmonary vein balloon angioplasty (PBA) or pulmonary vein stent implantation (PSI).
AIM To study the safety and efficacy outcomes of PBA vs PSI in all patient categories with PVS.
METHODS We performed a literature search of all studies comparing outcomes of patients evaluated by PBA vs PSI for PVS. We selected all published studies comparing PBA vs PSI for PVS with reported outcomes of restenosis and procedure-related complications in all patient categories. In adults, PVS following atrial fibrillation ablation and in children PVS related to congenital etiology or post-procedural PVS following total or partial anomalous pulmonary venous return repair were included. The patient-centered outcomes were risk of restenosis requiring re-intervention and procedural-related complications. The meta-analysis was performed by computing odds ratios (ORs) using the random effects model based on underlying statistical heterogeneity.
RESULTS Eight observational studies treating 768 severe PVS in 487 patients met our inclusion criteria. The age range of patients was 6 months to 70 years and 67% were males. The primary outcome of the re-stenosis requiring re-intervention occurred in 196 of 325 veins in the PBA group and 111 of 443 veins in the PSI group. Compared to PSI, PBA was associated with a significantly increased risk of re-stenosis (OR 2.91, 95%CI: 1.15-7.37, P = 0.025, I2 = 79.2%). Secondary outcomes of the procedure-related complications occurred in 7 of 122 patients in the PBA group and 6 of 69 in the PSI group. There were no statistically significant differences in the safety outcomes between the two groups (OR: 0.94, 95%CI: 0.23-3.76, P = 0.929), I2 = 0.0%).
CONCLUSION Across all patient categories with PVS, PSI is associated with reduced risk of re-intervention and is as safe as PBA and should be considered first-line therapy for PVS.
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Affiliation(s)
- Pradyumna Agasthi
- Department of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ 85259, United States
| | - Srilekha Sridhara
- Department of Internal Medicine, Banner Heart Hospital, Mesa, AZ 85054, United States
| | - Pattara Rattanawong
- Department of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ 85259, United States
| | - Nithin Venepally
- Department of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ 85259, United States
| | - Chieh-Ju Chao
- Department of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ 85259, United States
| | - Hasan Ashraf
- Department of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ 85259, United States
| | - Sai Harika Pujari
- Department of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ 85259, United States
| | - Mohamed Allam
- Department of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ 85259, United States
| | | | - Yamini Alla
- Department of Medicine, Bronx Lebanon Hospital, Bronx, NY 10457, United States
| | - Amit Kumar
- Department of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ 85259, United States
| | - Farouk Mookadam
- Department of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ 85259, United States
| | - Douglas L Packer
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905, United States
| | - David R Holmes Jr
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905, United States
| | - Donald J Hagler
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905, United States
| | - Floyd David Fortuin
- Department of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ 85259, United States
| | - Reza Arsanjani
- Department of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ 85259, United States
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7
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Zeitler EP, Li Y, Silverstein AP, Russo AM, Poole JE, Daniels MR, Al‐Khalidi HR, Lee KL, Bahnson T, Anstrom KJ, Packer DL, Mark DB. Effects of Ablation Versus Drug Therapy on Quality of Life by Sex in Atrial Fibrillation: Results From the CABANA Trial. J Am Heart Assoc 2023; 12:e027871. [PMID: 36688367 PMCID: PMC9973617 DOI: 10.1161/jaha.122.027871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 12/13/2022] [Indexed: 01/24/2023]
Abstract
Background Women with atrial fibrillation (AF) demonstrate more AF-related symptoms and worse quality of life (QOL). Whether increased use of ablation in women reduces sex-related QOL differences is unknown. Sex-related outcomes for ablation versus drug therapy was a prespecified analysis in the CABANA (Catheter Ablation Versus Antiarrhythmic Drug Therapy for Atrial Fibrillation) trial. Methods and Results Symptoms were assessed periodically over 60 months with the Mayo AF-Specific Symptom Inventory (MAFSI) frequency score, and QOL was assessed with the Atrial Fibrillation Effect on Quality of Life (AFEQT) summary and component scores. Women had lower baseline QOL scores than men (mean AFEQT scores 55.9 and 65.6, respectively). Ablation patients improved more than drug therapy patients with similar treatment effect by sex: AFEQT 12-month mean adjusted treatment difference in women 6.1 points (95% CI, 3.5-8.6) and men 4.9 points (95% CI, 3.0-6.9). Participants with baseline AFEQT summary scores <70 had greater QOL improvement, with a mean treatment difference at 12 months of 7.6 points for women (95% CI, 4.3-10.9) and 6.4 points for men (95% CI, 3.3-9.4). The mean adjusted difference in MAFSI frequency score between women randomized to ablation versus drug therapy at 12 months was -2.5 (95% CI, -3.4 to -1.6); for men, the difference was -1.3 (95% CI, -2.0 to -0.6). Conclusions Compared with drug therapy for AF, ablation resulted in more QOL improvement in both sexes, primarily driven by improvements in those with lower baseline QOL. Ablation did not eliminate the AF-related QOL gap between women and men. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT00911508.
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Affiliation(s)
| | - Yanhong Li
- Duke Clinical Research Institute, Duke UniversityDurhamNCUSA
| | | | - Andrea M. Russo
- Division of Cardiovascular DiseaseCooper Medical School of Rowan UniversityCamdenNJUSA
| | | | | | - Hussein R. Al‐Khalidi
- Duke Clinical Research Institute, Duke UniversityDurhamNCUSA
- Department of Biostatistics and BioinformaticsDuke UniversityDurhamNCUSA
| | - Kerry L. Lee
- Duke Clinical Research Institute, Duke UniversityDurhamNCUSA
- Department of Biostatistics and BioinformaticsDuke UniversityDurhamNCUSA
| | - Tristram D. Bahnson
- Duke Clinical Research Institute, Duke UniversityDurhamNCUSA
- Division of Cardiology, Department of MedicineDuke University Medical CenterDurhamNCUSA
| | | | | | - Daniel B. Mark
- Duke Clinical Research Institute, Duke UniversityDurhamNCUSA
- Division of Cardiology, Department of MedicineDuke University Medical CenterDurhamNCUSA
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8
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Nguyen DT, Bilchick KC, Narayan SM, Chung MK, Thomas KL, Laurita KR, Vaseghi M, Sandhu R, Chelu MG, Kannankeril PJ, Packer DL, McManus DD, Verma A, Singleton M, Tarakji K, Al-Khatib SM, Kaltman JR, Balijepalli RC, Van Hare GF, Hurwitz JL, Russo AM, Kusumoto FM, Albert CM. Opportunities and challenges in heart rhythm research: Rationale and development of an electrophysiology collaboratory. Heart Rhythm 2022; 19:1927-1945. [PMID: 37850602 PMCID: PMC10824490 DOI: 10.1016/j.hrthm.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 08/02/2022] [Indexed: 11/04/2022]
Abstract
There are many challenges in the current landscape of electrophysiology (EP) clinical and translational research, including increasing costs and complexity, competing demands, regulatory requirements, and challenges with study implementation. This review seeks to broadly discuss the state of EP research, including challenges and opportunities. Included here are results from a Heart Rhythm Society (HRS) Research Committee member survey detailing HRS members' perspectives regarding both barriers to clinical and translational research and opportunities to address these challenges. We also provide stakeholder perspectives on barriers and opportunities for future EP research, including input from representatives of the U.S. Food and Drug Administration, industry, and research funding institutions that participated in a Research Collaboratory Summit convened by HRS. This review further summarizes the experiences of the heart failure and heart valve communities and how they have approached similar challenges in their own fields. We then explore potential solutions, including various models of research ecosystems designed to identify research challenges and to coordinate ways to address them in a collaborative fashion in order to optimize innovation, increase efficiency of evidence generation, and advance the development of new therapeutic products. The objectives of the proposed collaborative cardiac EP research community are to encourage and support scientific discourse, research efficiency, and evidence generation by exploring collaborative and equitable solutions in which stakeholders within the EP community can interact to address knowledge gaps, innovate, and advance new therapies.
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Affiliation(s)
| | | | | | - Mina K Chung
- Department of Cardiology, Cleveland Clinic, Cleveland, Ohio
| | | | | | - Marmar Vaseghi
- University of California, Los Angeles Cardiac Arrhythmia Center, Los Angeles, California
| | - Roopinder Sandhu
- Department of Cardiology and Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | | | | | | | - David D McManus
- University of Massachusetts Medical School, Worcester, Massachusetts
| | - Atul Verma
- Southlake Regional Health Center, Toronto, Ontario, Canada
| | | | | | | | | | - Ravi C Balijepalli
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - George F Van Hare
- Office of Cardiovascular Devices, Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, Maryland
| | | | | | | | - Christine M Albert
- Department of Cardiology and Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
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9
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Almakadma A, Simard TJ, Sarma D, Hassett L, Alkhouli M, Packer DL, Holmes DR. Pulmonary vein stenosis – ballooning vs. stenting: a systematic review and meta-analysis. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Pulmonary vein stenosis (PVS), which is often unrecognized, may arise from a variety of conditions resulting in major morbidity and mortality. In some patients, pharmacological therapy may help but more often in advance stages, mechanical treatment must be considered. Transcatheter approaches, both balloon angioplasty (BA) and stent implantation have been applied. While both may be effective, they continue to be limited by restenosis. Herein, we compare the outcomes following BA and stenting for PVS.
Purpose
PVS presents a challenge for both diagnosis and therapy, with BA and stenting being primarily limited by restenosis. Stenting is performed in most cases and is associated with improved patency rates. Historical comparisons of BA and stenting for PVS have yielded similar results. Our analysis incorporates more conventional studies (2010–2021) and provides a larger stent (N=361) versus BA (N=229) contemporary analysis of the current state of PV intervention practice.
Methods
From January 1, 2010 to August 2, 2021, studies, limited to English language and humans, were assessed in Ovid MEDLINE®, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus. Two independent reviewers screened articles including those in which balloon angioplasty or stenting was performed for pulmonary vein stenosis with reporting of restenosis outcomes and data was independently extracted. Systematic review was performed, and overall restenosis rates were reported across all included studies. Meta-analysis was then performed using RevMan 5.4 assessing rates of restenosis and restenosis requiring repeat intervention.
Results
Our systematic review yielded 34 studies reporting on BA and/or stenting for PVS. Of these, 7 studies (1–7), treating a total of 343 patients with 590 PV interventions (229 BA and 361 Stents) reported restenosis rates with mean follow-up ranging from 10 to 60 months. Stenting was associated with a lower risk of restenosis compared to balloon angioplasty [risk ratio 0.35, 95% CI (0.18, 0.64), p=0.0008] (Figure 1). Restenosis requiring repeat intervention was reported in 5 studies, including 303 patients with 502 PV interventions (160 BA and 342 Stents) with stenting similarly associated with a lower risk of restenosis requiring re-intervention [risk ratio 0.34, 95% CI (0.16, 0.72), p=0.005].
Conclusion
Stenting for pulmonary vein stenosis is associated with reduced risk of restenosis and re-intervention as compared to balloon angioplasty.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- A Almakadma
- Mayo Clinic, Cardiovascular Diseases , Rochester , United States of America
| | - T J Simard
- Mayo Clinic, Cardiovascular Diseases , Rochester , United States of America
| | - D Sarma
- Mayo Clinic, Cardiovascular Diseases , Rochester , United States of America
| | - L Hassett
- Mayo Clinic, Mayo Clinic Libraries , Rochester , United States of America
| | - M Alkhouli
- Mayo Clinic, Cardiovascular Diseases , Rochester , United States of America
| | - D L Packer
- Mayo Clinic, Cardiovascular Diseases , Rochester , United States of America
| | - D R Holmes
- Mayo Clinic, Cardiovascular Diseases , Rochester , United States of America
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10
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Sarma D, Gladden J, Reeder GS, Munger TM, Packer DL, Holmes DR, Simard T. Prominent Collateral Vessels in Pulmonary Vein Occlusion. JACC Cardiovasc Interv 2022; 15:e223-e224. [DOI: 10.1016/j.jcin.2022.08.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 08/09/2022] [Accepted: 08/16/2022] [Indexed: 11/06/2022]
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11
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Almakadma AH, Sarma D, Hassett L, Miranda W, Alkhouli M, Reeder GS, Munger TM, Packer DL, Simard T, Holmes DR. Pulmonary Vein Stenosis-Balloon Angioplasty Versus Stenting: A Systematic Review and Meta-Analysis. JACC Clin Electrophysiol 2022; 8:1323-1333. [PMID: 36117046 DOI: 10.1016/j.jacep.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 08/05/2022] [Accepted: 08/10/2022] [Indexed: 10/14/2022]
Abstract
Pulmonary vein stenosis (PVS) may arise from a variety of conditions and result in major morbidity and mortality. In some patients, pharmacologic therapy may help, but more often in advanced stages, mechanical treatment must be considered. Transcatheter approaches, both balloon angioplasty (BA) and stent implantation, have been applied. Although both are effective, they continue to be limited by restenosis. In this systematic review and meta-analysis, Ovid MEDLINE, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus were searched for English-language studies in humans published between January 1, 2010, and August 2, 2021. Two independent reviewers screened for studies in which BA or stenting was performed for PVS with reporting of restenosis outcomes, and data were independently extracted. A systematic review was performed, and overall restenosis rates were reported across all 34 included studies. Meta-analysis was then performed using RevMan version 5.4, assessing rates of restenosis and restenosis requiring reintervention. For restenosis rates, 4 studies treated in those studies with available data reported. For restenosis rates, 4 studies treated a total of 340 patients with 579 pulmonary vein interventions (225 with BA and 354 with stenting, mean follow-up 13-69 months). Restenosis requiring repeat intervention was reported in 3 studies, including 301 patients with 495 pulmonary vein interventions (157 with BA and 338 with stenting). Compared with BA, stenting was associated with both a lower risk for restenosis (risk ratio: 0.36; 95% CI: 0.18-0.73; P = 0.005) and a lower risk for restenosis requiring reintervention (RR: 0.36; 95% CI: 0.15-0.86; P = 0.02). For PVS intervention, restenosis and reintervention rates may be improved by stent implantation compared with BA.
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Affiliation(s)
- Abdul Hakim Almakadma
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Dhruv Sarma
- Department of Internal Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Leslie Hassett
- Mayo Clinic Libraries, Mayo Clinic, Rochester, Minnesota, USA
| | - William Miranda
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Guy S Reeder
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Thomas M Munger
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Douglas L Packer
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Trevor Simard
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - David R Holmes
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA.
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12
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Chew DS, Li Y, Cowper PA, Anstrom KJ, Piccini JP, Poole JE, Daniels MR, Monahan KH, Davidson-Ray L, Bahnson TD, Al-Khalidi HR, Lee KL, Packer DL, Mark DB. Cost-Effectiveness of Catheter Ablation Versus Antiarrhythmic Drug Therapy in Atrial Fibrillation: The CABANA Randomized Clinical Trial. Circulation 2022; 146:535-547. [PMID: 35726631 PMCID: PMC9378541 DOI: 10.1161/circulationaha.122.058575] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND In the CABANA trial (Catheter Ablation vs Antiarrhythmic Drug Therapy for Atrial Fibrillation), catheter ablation did not significantly reduce the primary end point of death, disabling stroke, serious bleeding, or cardiac arrest compared with drug therapy by intention-to-treat, but did improve the quality of life and freedom from atrial fibrillation recurrence. In the heart failure subgroup, ablation improved both survival and quality of life. Cost-effectiveness was a prespecified CABANA secondary end point. METHODS Medical resource use data were collected for all CABANA patients (N=2204). Costs for hospital-based care were assigned using prospectively collected bills from US patients (n=1171); physician and medication costs were assigned using the Medicare Fee Schedule and National Average Drug Acquisition Costs, respectively. Extrapolated life expectancies were estimated using age-based survival models. Quality-of-life adjustments were based on EQ-5D-based utilities measured during the trial. The primary outcome was the incremental cost-effectiveness ratio, comparing ablation with drug therapy on the basis of intention-to-treat, and assessed from the US health care sector perspective. RESULTS Costs in the first 3 months averaged $20 794±SD 1069 higher with ablation compared with drug therapy. The cumulative within-trial 5-year cost difference was $19 245 (95% CI, $11 360-$27 170) and the lifetime mean cost difference was $15 516 (95% CI, -$2963 to $35,512) higher with ablation than with drug therapy. The drug therapy arm accrued an average of 12.5 life-years (LYs) and 10.7 quality-adjusted life-years (QALYs). For the ablation arm, the corresponding estimates were 12.6 LYs and 11.0 QALYs. The incremental cost-effectiveness ratio was $57 893 per QALY gained, with 75% of bootstrap replications yielding an incremental cost-effectiveness ratio <$100 000 per QALY gained. With no quality-of-life/utility adjustments, the incremental cost-effectiveness ratio was $183 318 per LY gained. CONCLUSIONS Catheter ablation of atrial fibrillation was economically attractive compared with drug therapy in the CABANA Trial overall at present benchmarks for health care value in the United States on the basis of projected incremental QALYs but not LYs alone.
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Affiliation(s)
- Derek S Chew
- Duke Clinical Research Institute (D.S.C., Y.L., P.A.C., K.J.A., J.P.P., M.R.D., L.D.-R., T.D.B., H.R.A.-K., K.L.L., D.B.M.), Duke University, Durham, NC
- Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Alberta, Canada (D.S.C.)
| | - Yanhong Li
- Duke Clinical Research Institute (D.S.C., Y.L., P.A.C., K.J.A., J.P.P., M.R.D., L.D.-R., T.D.B., H.R.A.-K., K.L.L., D.B.M.), Duke University, Durham, NC
| | - Patricia A Cowper
- Duke Clinical Research Institute (D.S.C., Y.L., P.A.C., K.J.A., J.P.P., M.R.D., L.D.-R., T.D.B., H.R.A.-K., K.L.L., D.B.M.), Duke University, Durham, NC
| | - Kevin J Anstrom
- Duke Clinical Research Institute (D.S.C., Y.L., P.A.C., K.J.A., J.P.P., M.R.D., L.D.-R., T.D.B., H.R.A.-K., K.L.L., D.B.M.), Duke University, Durham, NC
- Department of Biostatistics and Bioinformatics (K.J.A., H.R.A.-K., K.L.L.), Duke University, Durham, NC
- Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC (K.J.A.)
| | - Jonathan P Piccini
- Duke Clinical Research Institute (D.S.C., Y.L., P.A.C., K.J.A., J.P.P., M.R.D., L.D.-R., T.D.B., H.R.A.-K., K.L.L., D.B.M.), Duke University, Durham, NC
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (J.P.P., T.D.B., D.B.M.)
| | - Jeanne E Poole
- University of Washington Medical Center, Seattle (J.E.P.)
| | - Melanie R Daniels
- Duke Clinical Research Institute (D.S.C., Y.L., P.A.C., K.J.A., J.P.P., M.R.D., L.D.-R., T.D.B., H.R.A.-K., K.L.L., D.B.M.), Duke University, Durham, NC
| | | | - Linda Davidson-Ray
- Duke Clinical Research Institute (D.S.C., Y.L., P.A.C., K.J.A., J.P.P., M.R.D., L.D.-R., T.D.B., H.R.A.-K., K.L.L., D.B.M.), Duke University, Durham, NC
| | - Tristram D Bahnson
- Duke Clinical Research Institute (D.S.C., Y.L., P.A.C., K.J.A., J.P.P., M.R.D., L.D.-R., T.D.B., H.R.A.-K., K.L.L., D.B.M.), Duke University, Durham, NC
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (J.P.P., T.D.B., D.B.M.)
| | - Hussein R Al-Khalidi
- Duke Clinical Research Institute (D.S.C., Y.L., P.A.C., K.J.A., J.P.P., M.R.D., L.D.-R., T.D.B., H.R.A.-K., K.L.L., D.B.M.), Duke University, Durham, NC
- Department of Biostatistics and Bioinformatics (K.J.A., H.R.A.-K., K.L.L.), Duke University, Durham, NC
| | - Kerry L Lee
- Duke Clinical Research Institute (D.S.C., Y.L., P.A.C., K.J.A., J.P.P., M.R.D., L.D.-R., T.D.B., H.R.A.-K., K.L.L., D.B.M.), Duke University, Durham, NC
- Department of Biostatistics and Bioinformatics (K.J.A., H.R.A.-K., K.L.L.), Duke University, Durham, NC
| | | | - Daniel B Mark
- Duke Clinical Research Institute (D.S.C., Y.L., P.A.C., K.J.A., J.P.P., M.R.D., L.D.-R., T.D.B., H.R.A.-K., K.L.L., D.B.M.), Duke University, Durham, NC
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (J.P.P., T.D.B., D.B.M.)
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13
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Packer DL, Wilber DJ, Kapa S, Dyrda K, Nault I, Killu AM, Kanagasundram A, Richardson T, Stevenson W, Verma A, Curley M. Ablation of Refractory Ventricular Tachycardia Using Intramyocardial Needle Delivered Heated Saline-Enhanced Radiofrequency Energy: a First-in-Man Feasibility Trial. Circ Arrhythm Electrophysiol 2022; 15:e010347. [PMID: 35776711 PMCID: PMC9388560 DOI: 10.1161/circep.121.010347] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Ablation of ventricular tachycardia (VT) is limited by the inability to create penetrating lesions to reach intramyocardial origins. Intramural needle ablation using in-catheter, heated saline-enhanced radio frequency (SERF) energy uses convective heating to increase heat transfer and produce deeper, controllable lesions at intramural targets. This first-in-human trial was designed to evaluate the safety and efficacy of SERF needle ablation in patients with refractory VT. METHODS Thirty-two subjects from 6 centers underwent needle electrode ablation. Each had recurrent drug-refractory monomorphic VT after implantable cardioverter defibrillator implantation and prior standard ablation. During the SERF study procedure, one or more VTs were induced and mapped. The SERF needle catheter was used to create intramural lesions at targeted VT site(s). Acute procedural success was defined as noninducibility of the clinical VT after the procedure. Patients underwent follow-up at 30 days, and 3 and 6 months, with implantable cardioverter defibrillator interrogation at follow-up to determine VT recurrence. RESULTS These refractory VT patients (91% male, 66±10 years, ejection fraction 35±11%; 56% ischemic, and 44% nonischemic) had a median of 45 device therapies (shock/antitachycardia pacing) for VT in the 3 to 6 months pre-SERF ablation. The study catheter was used to deliver an average of 10±5 lesions per case, with an average of 430±295 seconds of radiofrequency time, 122±65 minute of catheter use time, and a procedural duration of 4.3±1.3 hours. Acute procedural success was 97% for eliminating the clinical VT. At average follow-up of 5 months (n=32), device therapies were reduced by 89%. Complications included 2 periprocedural deaths: an embolic mesenteric infarct and cardiogenic shock, 2 mild strokes, and a pericardial effusion treated with pericardiocentesis (n=1). CONCLUSIONS Intramural heated saline needle ablation showed complete acute and satisfactory mid-term control of difficult VTs failing 1 to 5 prior ablations and drug therapy. Further study is warranted to define safety and longer-term efficacy. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique Identifier: NCT03628534 and NCT02994446.
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Affiliation(s)
| | | | - Suraj Kapa
- Mayo Clinic, Rochester, MN (D.L.P., S.K., A.M.K.)
| | | | - Isabelle Nault
- Canada Quebec Heart and Lung Institute, Quebec City, Canada (I.N.)
| | | | | | - Travis Richardson
- Vanderbilt University Medical Center, Nashville, TN (A.K., T.R., W.S.)
| | - William Stevenson
- Vanderbilt University Medical Center, Nashville, TN (A.K., T.R., W.S.)
| | - Atul Verma
- Southlake Regional Health Centre, Newmarket Ontario, Canada (A.V.)
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14
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Hindricks G, Packer DL. Catheter ablation of atrial fibrillation: recent advances and future challenges. Europace 2022; 24:ii1-ii2. [PMID: 35661864 PMCID: PMC9169057 DOI: 10.1093/europace/euac035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Gerhard Hindricks
- Corresponding authors. Tel: +493418651410, E-mail address: (G.H.); E-mail address: (D.P.)
| | - Douglas L Packer
- Corresponding authors. Tel: +493418651410, E-mail address: (G.H.); E-mail address: (D.P.)
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15
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Monahan KH, Bunch TJ, Mark DB, Poole JE, Bahnson TD, Al-Khalidi HR, Silverstein AP, Daniels MR, Lee KL, Packer DL. Influence of atrial fibrillation type on outcomes of ablation vs. drug therapy: results from CABANA. Europace 2022; 24:1430-1440. [PMID: 35640922 DOI: 10.1093/europace/euac055] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 04/10/2022] [Indexed: 11/14/2022] Open
Abstract
AIMS Influence of atrial fibrillation (AF) type on outcomes seen with catheter ablation vs. drug therapy is incompletely understood. This study assesses the impact of AF type on treatment outcomes in the Catheter Ablation vs. Antiarrhythmic Drug Therapy for Atrial Fibrillation Trial (CABANA). METHODS AND RESULTS CABANA randomized 2204 patients ≥65 years old or <65 with at least one risk factor for stroke to catheter ablation or drug therapy. Of these, 946 (42.9%) had paroxysmal AF (PAF), 1042 (47.3%) had persistent AF (PersAF), and 215 (9.8%) had long-standing persistent AF (LSPAF) at baseline. The primary endpoint was a composite of death, disabling stroke, serious bleeding, or cardiac arrest. Symptoms were measured with the Mayo AF-Specific Symptom Inventory (MAFSI), and quality of life was measured with the Atrial Fibrillation Effect on Quality of Life (AFEQT). Comparisons are reported by intention to treat. Compared with drug therapy alone, catheter ablation produced a 19% relative risk reduction in the primary endpoint for PAF {adjusted hazard ratio [aHR]: 0.81 [95% confidence interval (CI): 0.50, 1.30]}, and a 17% relative reduction for PersAF (aHR: 0.83, 95% CI: 0.56, 1.22). For LSPAF, the ablation relative effect was a 7% reduction (aHR: 0.93, 95% CI: 0.36, 2.44). Ablation was more effective than drug therapy at reducing first AF recurrence in all AF types: by 51% for PAF (aHR: 0.49, 95% CI: 0.39, 0.62), by 47% for PersAF (aHR: 0.53, 95% CI: 0.43,0.65), and by 36% for LSPAF (aHR 0.64, 95% CI 0.41,1.00). Ablation was associated with greater improvement in symptoms, with the mean difference between groups in the MAFSI frequency score favouring ablation over 5 years of follow-up in all subgroups: PAF had a clinically significant -1.9-point difference (95% CI: -1.2 to -2.6); PersAF a -0.9 difference (95% CI: -0.2 to -1.6); LSPAF a clinically significant difference of -1.6 points (95% CI: -0.1 to -3.1). Ablation was also associated with greater improvement in quality of life in all subgroups, with the AFEQT overall score in PAF patients showing a clinically significant 5.3-point improvement (95% CI: 3.3 to 7.3) over drug therapy alone over 5 years of follow-up, PersAF a 1.7-point difference (95% CI: 0.0 to 3.7), and LSPAF a 3.1-point difference (95% CI: -1.6 to 7.8). CONCLUSION Prognostic treatment effects of catheter ablation compared with drug therapy on the primary and major secondary clinical endpoints did not differ consequentially by AF subtype. With regard to decreases in AF recurrence and improving quality of life, ablation was more effective than drug therapy in all three AF type subgroups. CLINICALTRIALS.GOV IDENTIFIER NCT00911508.
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Affiliation(s)
| | - T Jared Bunch
- Intermountain Health Care, University of Utah, Salt Lake City, UT 84132, USA
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University, Durham, NC 27701, USA
| | - Jeanne E Poole
- University of Washington Medical Center, University of Washington, Seattle, WA 98195, USA
| | - Tristram D Bahnson
- Duke Clinical Research Institute, Duke University, Durham, NC 27701, USA
| | | | - Adam P Silverstein
- Duke Clinical Research Institute, Duke University, Durham, NC 27701, USA
| | - Melanie R Daniels
- Duke Clinical Research Institute, Duke University, Durham, NC 27701, USA
| | - Kerry L Lee
- Duke Clinical Research Institute, Duke University, Durham, NC 27701, USA
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16
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Dickow J, Kirchhof P, Van Houten HK, Sangaralingham LR, Dinshaw LHW, Friedman PA, Packer DL, Noseworthy PA, Yao X. Generalizability of the EAST-AFNET 4 Trial: Assessing Outcomes of Early Rhythm-Control Therapy in Patients With Atrial Fibrillation. J Am Heart Assoc 2022; 11:e024214. [PMID: 35621202 PMCID: PMC9238730 DOI: 10.1161/jaha.121.024214] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Background EAST‐AFNET 4 (Early Treatment of Atrial Fibrillation for Stroke Prevention Trial) demonstrated clinical benefit of early rhythm‐control therapy (ERC) in patients with new‐onset atrial fibrillation (AF) and concomitant cardiovascular conditions compared with current guideline‐based practice. This study aimed to evaluate the generalizability of EAST‐AFNET 4 in routine practice. Methods and Results Using a US administrative database, we identified 109 739 patients with newly diagnosed AF during the enrollment period of EAST‐AFNET 4. Patients were classified as either receiving ERC, using AF ablation or antiarrhythmic drug therapy, within the first year after AF diagnosis (n=27 106) or not receiving ERC (control group, n=82 633). After propensity score overlap weighting, Cox proportional hazards regression was used to compare groups for the primary composite outcome of all‐cause mortality, stroke, or hospitalization with the diagnoses heart failure or myocardial infarction. Most patients (79 948 of 109 739; 72.9%) met the inclusion criteria for EAST‐AFNET 4. ERC was associated with a reduced risk for the primary composite outcome (hazard ratio [HR], 0.85; 95% CI, 0.75–0.97 [P=0.02]) with largely consistent results between eligible (HR, 0.89; 95% CI, 0.76–1.04 [P=0.14]) or ineligible (HR, 0.77; 95% CI, 0.60–0.98 [P=0.04]) patients for EAST‐AFNET 4 trial inclusion. ERC was associated with lower risk of stroke in the overall cohort and in trial‐eligible patients. Conclusions This analysis replicates the clinical benefit of ERC seen in EAST‐AFNET 4. The results support adoption of ERC as part of the management of recently diagnosed AF in the United States.
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Affiliation(s)
- Jannis Dickow
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN.,Department of Cardiology University Heart and Vascular Center HamburgUniversity Hospital Hamburg Eppendorf Hamburg Germany.,DZHK (German Center for Cardiovascular Research)Partner Site Hamburg/Kiel/Lübeck Berlin Germany
| | - Paulus Kirchhof
- Department of Cardiology University Heart and Vascular Center HamburgUniversity Hospital Hamburg Eppendorf Hamburg Germany.,DZHK (German Center for Cardiovascular Research)Partner Site Hamburg/Kiel/Lübeck Berlin Germany.,Institute of Cardiovascular SciencesUniversity of Birmingham Birmingham United Kingdom
| | - Holly K Van Houten
- OptumLabs Eden Prairie MN.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic Rochester MN
| | - Lindsey R Sangaralingham
- OptumLabs Eden Prairie MN.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic Rochester MN
| | - Leon H W Dinshaw
- Department of Cardiology University Heart and Vascular Center HamburgUniversity Hospital Hamburg Eppendorf Hamburg Germany
| | - Paul A Friedman
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | | | - Peter A Noseworthy
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic Rochester MN
| | - Xiaoxi Yao
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic Rochester MN
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Hirao T, Imamura K, Suzuki A, Deisher AJ, Rettmann M, DICKOW J, Yasin OZ, Kowlgi GN, Packer DL. BS-400-04 BIOCHEMICAL EFFECTS OF CATHETER-FREE VENTRICULAR ABLATION WITH PROTON BEAM ABLATION THERAPY IN NORMAL SWINE HEART. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.1205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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Yasin OZ, Hirao T, Kowlgi GN, Rettmann M, Deisher AJ, Suzuki A, Imamura K, DICKOW J, Reddy P, Newman K, Packer DL. PO-705-04 CHARACTERISTICS OF PROTON BEAM ABLATION LESIONS COMPARED TO ISCHEMIA RELATED INFARCT ON MAGNETIC RESONANCE IMAGING. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.1075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Hirao T, Imamura K, Suzuki A, Deisher AJ, Rettmann M, DICKOW JANNIS, Yasin OZ, Kowlgi GN, Packer DL. PO-645-02 BIOCHEMICAL EFFECTS OF CATHETER-FREE VENTRICULAR ABLATION WITH PROTON BEAM ABLATION THERAPY IN NORMAL SWINE HEART. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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20
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Bahnson TD, Giczewska A, Mark DB, Russo AM, Monahan KH, Al-Khalidi HR, Silverstein AP, Poole JE, Lee KL, Packer DL. Association Between Age and Outcomes of Catheter Ablation Versus Medical Therapy for Atrial Fibrillation: Results From the CABANA Trial. Circulation 2022; 145:796-804. [PMID: 34933570 PMCID: PMC9003625 DOI: 10.1161/circulationaha.121.055297] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Observational data suggest that catheter ablation may be safe and effective to treat younger and older patients with atrial fibrillation. No large, randomized trial has examined this issue. This report describes outcomes according to age at entry in the CABANA trial (Catheter Ablation versus Antiarrhythmic Drug Therapy for Atrial Fibrillation). METHODS Patients with atrial fibrillation ≥65 years of age, or <65 with ≥1 risk factor for stroke, were randomly assigned to catheter ablation versus drug therapy. The primary outcome was a composite of death, disabling stroke, serious bleeding, or cardiac arrest. Secondary outcomes included all-cause mortality, the composite of mortality or cardiovascular hospitalization, and recurrence of atrial fibrillation. Treatment effect estimates were adjusted for baseline covariables using proportional hazards regression models. RESULTS Of 2204 patients randomly assigned in CABANA, 766 (34.8%) were <65 years of age, 1130 (51.3%) were 65 to 74 years of age, and 308 (14.0%) were ≥75 years of age. Catheter ablation was associated with a 43% reduction in the primary outcome for patients <65 years of age (adjusted hazard ratio [aHR], 0.57 [95% CI, 0.30-1.09]), a 21% reduction for 65 to 74 years of age (aHR, 0.79 [95% CI, 0.54-1.16]), and an indeterminate effect for age ≥75 years of age (aHR, 1.39 [95% CI, 0.75-2.58]). Four-year event rates for ablation versus drug therapy across age groups, respectively, were 3.2% versus 7.8%, 7.8% versus 9.6%, and 14.8% versus 9.0%. For every 10-year increase in age, the primary outcome aHR increased (ie, less favorable to ablation) an average of 27% (interaction P value=0.215). A similar pattern was seen with all-cause mortality: for every 10-year increase in age, the aHR increased an average of 46% (interaction P value=0.111). Atrial fibrillation recurrence rates were lower with ablation than with drug therapy across age subgroups (aHR 0.47, 0.58, and 0.49, respectively). Treatment-related complications were infrequent for both arms (<3%) regardless of age. CONCLUSIONS We found age-based variations in clinical outcomes for catheter ablation compared with drug therapy, with the largest relative and absolute benefits of catheter ablation in younger patients. No prognostic benefits for ablation were seen in the oldest patients. No differences were found by age in treatment-related complications or in the relative effectiveness of catheter ablation in preventing recurrent atrial arrhythmias. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT00911508.
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Affiliation(s)
- Tristram D Bahnson
- Duke Clinical Research Institute, Duke University, Durham, NC (T.D.B., A.G., D.B.M., H.R.A.-K., A.P.S., K.L.L.).,Duke Center for Atrial Fibrillation, Duke Health System, Durham, NC (T.D.B.)
| | - Anna Giczewska
- Duke Clinical Research Institute, Duke University, Durham, NC (T.D.B., A.G., D.B.M., H.R.A.-K., A.P.S., K.L.L.)
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University, Durham, NC (T.D.B., A.G., D.B.M., H.R.A.-K., A.P.S., K.L.L.)
| | - Andrea M Russo
- Duke Clinical Research Institute, Duke University, Durham, NC (T.D.B., A.G., D.B.M., H.R.A.-K., A.P.S., K.L.L.).,Cooper University Health System, Camden, NJ (A.M.R.)
| | | | - Hussein R Al-Khalidi
- Duke Clinical Research Institute, Duke University, Durham, NC (T.D.B., A.G., D.B.M., H.R.A.-K., A.P.S., K.L.L.)
| | - Adam P Silverstein
- Duke Clinical Research Institute, Duke University, Durham, NC (T.D.B., A.G., D.B.M., H.R.A.-K., A.P.S., K.L.L.)
| | - Jeanne E Poole
- University of Washington Medical Center, Seattle (J.E.P.)
| | - Kerry L Lee
- Duke Clinical Research Institute, Duke University, Durham, NC (T.D.B., A.G., D.B.M., H.R.A.-K., A.P.S., K.L.L.)
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Verma A, Boersma L, Haines DE, Natale A, Marchlinski FE, Sanders P, Calkins H, Packer DL, Hummel J, Onal B, Rosen S, Kuck KH, Hindricks G, Wilsmore B. First-in-Human Experience and Acute Procedural Outcomes Using a Novel Pulsed Field Ablation System: The PULSED AF Pilot Trial. Circ Arrhythm Electrophysiol 2021; 15:e010168. [PMID: 34964367 PMCID: PMC8772438 DOI: 10.1161/circep.121.010168] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Pulsed field ablation (PFA) is a novel form of ablation using electrical fields to ablate cardiac tissue. There are only limited data assessing the feasibility and safety of this type of ablation in humans. Methods: PULSED AF (Pulsed Field Ablation to Irreversibly Electroporate Tissue and Treat AF; https://www.clinicaltrials.gov; unique identifier: NCT04198701) is a nonrandomized, prospective, multicenter, global, premarket clinical study. The first-in-human pilot phase evaluated the feasibility and efficacy of pulmonary vein isolation using a novel PFA system delivering bipolar, biphasic electrical fields through a circular multielectrode array catheter (PulseSelect; Medtronic, Inc). Thirty-eight patients with paroxysmal or persistent atrial fibrillation were treated in 6 centers in Australia, Canada, the United States, and the Netherlands. The primary outcomes were ability to achieve acute pulmonary vein isolation intraprocedurally and safety at 30 days. Results: Acute electrical isolation was achieved in 100% of pulmonary veins (n=152) in the 38 patients. Skin-to-skin procedure time was 160±91 minutes, left atrial dwell time was 82±35 minutes, and fluoroscopy time was 28±9 minutes. No serious adverse events related to the PFA system occurred in the 30-day follow-up including phrenic nerve injury, esophageal injury, stroke, or death. Conclusions: In this first-in-human clinical study, 100% pulmonary vein isolation was achieved using only PFA with no PFA system–related serious adverse events. Graphic Abstract: A graphic abstract is available for this article.
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Affiliation(s)
- Atul Verma
- Southlake Regional Health Centre, Newmarket, Canada (A.V.)
| | - Lucas Boersma
- St. Antonius Hospital, Amsterdam, the Netherlands (L.B.)
| | | | | | | | | | | | | | - John Hummel
- OSU Wexner Medical Center, Columbus, OH (J.H.)
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Pavlovic N, Chierchia GB, Velagic V, Hermida JS, Healey S, Arena G, Badenco N, Meyer C, Chen J, Iacopino S, Anselme F, Dekker L, Scazzuso F, Packer DL, de Asmundis C, Pitschner HF, Piazza FD, Kaplon RE, Kuniss M. Initial rhythm control with cryoballoon ablation vs drug therapy: Impact on quality of life and symptoms. Am Heart J 2021; 242:103-114. [PMID: 34508694 DOI: 10.1016/j.ahj.2021.08.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 08/13/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Cryoballoon ablation (CBA) as a first-line rhythm control strategy is superior to antiarrhythmic drugs (AADs) for preventing atrial fibrillation (AF) recurrence; the impact of first-line CBA on quality of life (QoL) and symptoms has not been well characterized. METHODS Patients aged 18 to 75 with symptomatic paroxysmal AF naïve to rhythm control therapy were randomized (1:1) to CBA (Arctic Front Advance, Medtronic) or AAD (Class I or III). Symptoms and QoL were assessed at baseline, 1, 3, 6, 9, and 12 months using the EHRA classification and Atrial Fibrillation Effect on QualiTy-of-Life (AFEQT) and SF-36v2 questionnaires. Symptomatic palpitations were evaluated via patient diary. RESULTS Overall, 107 patients were randomized to CBA and 111 to AAD; crossovers occurred in 9%. Larger improvements in the AFEQT summary, subscale and treatment satisfaction scores were observed at 12 months with CBA vs AAD (all P <0.05). At 12 months, the mean adjusted difference in the AFEQT summary score was 9.9 points higher in the CBA group (95% CI: 5.5 -14.2, P <0.001). Clinically important improvements in the SF-36 physical and mental component scores were observed at 12 months in both groups, with no significant between group differences at this timepoint. In the CBA vs AAD group, larger improvements in EHRA class were observed at 6, 9 and 12 months (P <0.05) and the incidence rate of symptomatic palpitations was lower (4.6 vs 15.2 days/year post-blanking; IRR: 0.30, P <0.001). CONCLUSIONS In patients with symptomatic AF, first-line CBA was superior to AAD for improving AF-specific QoL and symptoms. TRIAL REGISTRATION ClinicalTrials.gov number: NCT01803438.
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Packer DL, Mark DB, Lee KL. CABANA: underpowered and with detrimental protocol changes: is 'ablation salvation'?-Reply by the authors of the CABANA trial. Europace 2021; 24:3. [PMID: 34792125 DOI: 10.1093/europace/euab237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University, Durham, NC 27701, USA
| | - Kerry L Lee
- Duke Clinical Research Institute, Duke University, Durham, NC 27701, USA
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Chew DS, Jones KA, Loring Z, Black-Maier E, Noseworthy PA, Exner DV, Packer DL, Grant J, Mark DB, Piccini JP. Diagnosis-to-ablation time predicts recurrent atrial fibrillation and rehospitalization following catheter ablation. Heart Rhythm O2 2021; 3:23-31. [PMID: 35243432 PMCID: PMC8859793 DOI: 10.1016/j.hroo.2021.11.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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Ingraham BS, Packer DL, Holmes DR, Reddy YNV. The hemodynamic spectrum of pulmonary vein stenosis from fibrosing mediastinitis. Catheter Cardiovasc Interv 2021; 99:198-200. [PMID: 34536328 DOI: 10.1002/ccd.29955] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 09/03/2021] [Indexed: 11/10/2022]
Abstract
A 63-year-old man presented with hemoptysis and progressive dyspnea. His echocardiogram was concerning for pulmonary hypertension (PH) and CT chest showed fibrosing mediastinitis with possible cardiac involvement. Right heart catheterization revealed PH at rest and worsened with exercise. CT findings and simultaneous measurement of pulmonary capillary wedge pressure (PCWP), left atrial pressure, and left ventricular pressure helped diagnose pulmonary vein (PV) stenosis as the etiology of his PH. Both upper pulmonary veins were stented, and repeat exercise hemodynamic study revealed a substantial reduction in pulmonary arterial pressure with improvement in subjective dyspnea, cardiac output reserve, mechanical efficiency, and ventilatory efficiency. Repeat right upper PCWP normalized, consistent with resolution of the PV stenosis.
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Affiliation(s)
- Brenden S Ingraham
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - David R Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Yogesh N V Reddy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Konishi H, Suzuki A, Hohmann S, Parker KD, Newman LK, Monahan KH, Rettmann ME, Packer DL. Comparison of Microemboli Formation Between Irrigated Catheter Tip Architecture Using a Microemboli Monitoring System. JACC Clin Electrophysiol 2021; 8:26-37. [PMID: 34454888 DOI: 10.1016/j.jacep.2021.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 06/15/2021] [Accepted: 06/16/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES This study aimed to compare the efficacy and safety of ablation with high and low power settings using either a flexible tip or straight SF tip irrigated catheter in the left ventricle (LV) using a peripheral microemboli monitoring system. BACKGROUND The microemboli risk of flexible and straight SF tip irrigated catheters in creating ablative lesions in the LV at variable power settings has not been adequately assessed. METHODS Six pigs underwent catheter ablation in the LV using a flexible tip or straight SF tip catheter with 2 energy settings (30 or 50 W, 30 seconds, irrigation saline 17 mL/min). RESULTS A total of 79 radiofrequency (RF) applications were assessed. High power settings via a flexible tip formed a significantly higher arterial microbubble volume in the extracorporeal circulation (P = 0.005). Notably, RF applications with a steam pop induced an exponential increase of microbubble volume with both catheters. A higher power setting induced a significantly higher number of microembolic signals on carotid artery Doppler ultrasound with a flexible tip irrigated catheter (P < 0.001). Similarly, the straight SF tip irrigated catheter tended to increase the number of microembolic signals with 50 W (P = 0.091). CONCLUSIONS RF ablation at high power settings in the LV carries a risk of microembolic events compared with lower power settings. When high power settings are used for creating ablative lesions for deep intramural foci in the LV, the risk of microembolic events induced by RF ablation should be carefully monitored.
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Affiliation(s)
- Hiroki Konishi
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Atsushi Suzuki
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Stephan Hohmann
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Kay D Parker
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Laura K Newman
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Kristi H Monahan
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Maryam E Rettmann
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Douglas L Packer
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic, Rochester, Minnesota, USA.
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Kuniss M, Pavlovic N, Velagic V, Hermida JS, Healey S, Arena G, Badenco N, Meyer C, Chen J, Iacopino S, Anselme F, Packer DL, Pitschner HF, Asmundis CD, Willems S, Di Piazza F, Becker D, Chierchia GB. Cryoballoon ablation vs. antiarrhythmic drugs: first-line therapy for patients with paroxysmal atrial fibrillation. Europace 2021; 23:1033-1041. [PMID: 33728429 PMCID: PMC8286851 DOI: 10.1093/europace/euab029] [Citation(s) in RCA: 104] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 01/25/2021] [Indexed: 12/15/2022] Open
Abstract
AIMS Treatment guidelines for patients with atrial fibrillation (AF) suggest that patients should be managed with an antiarrhythmic drug (AAD) before undergoing catheter ablation (CA). This study evaluated whether pulmonary vein isolation employing cryoballoon CA is superior to AAD therapy for the prevention of atrial arrhythmia (AA) recurrence in rhythm control naive patients with paroxysmal AF (PAF). METHODS AND RESULTS A total of 218 treatment naive patients with symptomatic PAF were randomized (1 : 1) to cryoballoon CA (Arctic Front Advance, Medtronic) or AAD (Class I or III) and followed for 12 months. The primary endpoint was ≥1 episode of recurrent AA (AF, atrial flutter, or atrial tachycardia) >30 s after a prespecified 90-day blanking period. Secondary endpoints included the rate of serious adverse events (SAEs) and recurrence of symptomatic palpitations (evaluated via patient diaries). Freedom from AA was achieved in 82.2% of subjects in the cryoballoon arm and 67.6% of subjects in the AAD arm (HR = 0.48, P = 0.01). There were no group differences in the time-to-first (HR = 0.76, P = 0.28) or overall incidence [incidence rate ratio (IRR)=0.79, P = 0.28] of SAEs. The incidence rate of symptomatic palpitations was lower in the cryoballoon (7.61 days/year) compared with the AAD arm (18.96 days/year; IRR = 0.40, P < 0.001). CONCLUSIONS Cryoballoon CA was superior to AAD therapy, significantly reducing AA recurrence in treatment naive patients with PAF. Additionally, cryoballoon CA was associated with lower symptom recurrence and a similar rate of SAEs compared with AAD therapy.
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Affiliation(s)
- Malte Kuniss
- Kerckhoff Heart Center, Benekestrasse 2-8, 61231 Bad Nauheim, Germany
| | - Nikola Pavlovic
- Sestre Milosrdnice University Hospital Centre, Zagreb, Croatia
| | | | | | | | | | - Nicolas Badenco
- AP-HP Sorbonne Université, ICAN Institute, Hopital Pitié-Salpétrière, Paris, France
| | - Christian Meyer
- University Heart Center, Hamburg, Cardiac Neuro- and Electrophysiology Research Consortium, EVK Düsseldorf, Düsseldorf, Germany
| | - Jian Chen
- Haukeland University Hospital, University of Bergen, Bergen, Norway
| | | | | | | | | | - Carlo de Asmundis
- Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel, Postgraduate program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Vrije Universiteit Brussel, Brussels, Belgium
| | - Stephan Willems
- University Heart Center, Hamburg, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Fabio Di Piazza
- Medtronic, Core Clinical Solutions, Study and Scientific Solutions, Rome, Italy
| | | | - Gian-Battista Chierchia
- Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel, Postgraduate program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Vrije Universiteit Brussel, Brussels, Belgium
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Zeitler EP, Russo AM, Silverstein A, Al-Khalidi HR, Monahan KH, Packer DL, Mark DB. B-PO05-069 SEX-SPECIFIC QUALITY OF LIFE OUTCOMES OF ABLATION VERSUS DRUG THERAPY FOR AF: INSIGHTS FROM CABANA. Heart Rhythm 2021. [DOI: 10.1016/j.hrthm.2021.06.989] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Dickow J, Wang S, Suzuki A, Imamura K, Lehmann HI, Parker KD, Newman LK, Monahan KH, Rettmann M, Curley MG, Packer DL. B-PO03-034 INTRACARDIAC ECHOCARDIOGRAPHY VALIDATION OF SALINE-ENHANCED RADIOFREQUENCY NEEDLE-TIP ABLATION FOR THE CONTROLLABLE CREATION OF TRANSMURAL LESIONS. Heart Rhythm 2021. [DOI: 10.1016/j.hrthm.2021.06.510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Thomas KL, Al-Khalidi HR, Silverstein AP, Monahan KH, Bahnson TD, Poole JE, Mark DB, Packer DL. Ablation Versus Drug Therapy for Atrial Fibrillation in Racial and Ethnic Minorities. J Am Coll Cardiol 2021; 78:126-138. [PMID: 34238436 DOI: 10.1016/j.jacc.2021.04.092] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/19/2021] [Accepted: 04/26/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Rhythm control strategies for atrial fibrillation (AF), including catheter ablation, are substantially underused in racial/ethnic minorities in North America. OBJECTIVES This study sought to describe outcomes in the CABANA trial as a function of race/ethnicity. METHODS CABANA randomized 2,204 symptomatic participants with AF to ablation or drug therapy including rate and/or rhythm control drugs. Only participants in North America were included in the present analysis, and participants were subgrouped as racial/ethnic minority or nonminority with the use of National Institutes of Health definitions. The primary endpoint was a composite of death, disabling stroke, serious bleeding, or cardiac arrest. RESULTS Of 1,280 participants enrolled in CABANA in North America, 127 (9.9%) were racial and ethnic minorities. Compared with nonminorities, racial and ethnic minorities were younger with median age 65.6 versus 68.5 years, respectively, and had more symptomatic heart failure (37.0% vs 22.0%), hypertension (92.1% vs 76.8%, respectively), and ejection fraction <40% (20.8% vs 7.1%). Racial/ethnic minorities treated with ablation had a 68% relative reduction in the primary endpoint (adjusted hazard ratio [aHR]: 0.32; 95% confidence interval [CI]: 0.13-0.78) and a 72% relative reduction in all-cause mortality (aHR: 0.28; 95% CI: 0.10-0.79). Primary event rates in racial/ethnic minority and nonminority participants were similar in the ablation arm (4-year Kaplan-Meier event rates 12.3% vs 9.9%); however, racial and ethnic minorities randomized to drug therapy had a much higher event rate than nonminority participants (27.4% vs. 9.4%). CONCLUSION Among racial or ethnic minorities enrolled in the North American CABANA cohort, catheter ablation significantly improved major clinical outcomes compared with drug therapy. These benefits, which were not seen in nonminority participants, appear to be due to worse outcomes with drug therapy. (Catheter Ablation vs Anti-arrhythmic Drug Therapy for Atrial Fibrillation Trial [CABANA]; NCT00911508).
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Affiliation(s)
- Kevin L Thomas
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA.
| | | | - Adam P Silverstein
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | | | - Tristram D Bahnson
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Jeanne E Poole
- University of Washington Medical Center, Seattle, Washington, USA
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
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Dickow J, Wang S, Suzuki A, Imamura K, Lehmann HI, Parker KD, Newman LK, Monahan KH, Rettmann ME, Curley MG, Packer DL. Real-time intracardiac echocardiography validation of saline-enhanced radiofrequency needle-tip ablation: lesion characteristics and gross pathology correlation. Europace 2021; 23:1826-1836. [PMID: 33993234 DOI: 10.1093/europace/euab121] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Indexed: 11/13/2022] Open
Abstract
AIMS With the implementation of saline-enhanced radiofrequency (SERF) needle-tip ablation, real-time validation of lesion formation is needed for the controllable creation of transmural lesions. The aim of the study was to analyse the ability of two-dimensional intracardiac echocardiography (2D-ICE) to guide and validate SERF ablation in real-time. METHODS AND RESULTS Fifty-six SERF energy deliveries at left ventricular sites of 11 dogs guided by 2D-ICE were analysed (power: 15-50 W; time: 25-120 s; irrigation saline: 60°C with 10 mL/min flow rate). Catheter tip/tissue orientation and lesion formation could be well detected by 2D-ICE in 49 (87.5%) energy deliveries. Gross pathology analysis confirmed excellent 2D-ICE lesion localization, the ability to detect transmural lesions (70% sensitivity, 47% specificity) and positive correlation between 2D-ICE and the corresponding gross pathology measurements of 'maximal lesion depth'; (repeated measures correlation: rrm = 0.43, P = 0.012) and 'depth at maximal lesion width' (D@MW; rrm = 0.51, P = 0.003). The median angle between SERF catheter tip and endocardium was 76° [interquartile range (IQR) 58-83°]. The more perpendicular the catheter tip/tissue orientation was the deeper D@MW (rrm = 0.32, P = 0.045). Grade 3 microbubbles on 2D-ICE during ablation, indicating inadequate catheter tip/tissue contact, was associated with smaller lesion volumes than with Grade 1 microbubbles (284.8 mm3 [IQR 151.3-343.1] vs. 2114.1 mm3 [IQR 1437.0-3026.3], P < 0.001). CONCLUSION With excellent lesion localization and a 70% detection rate of transmural lesions, 2D-ICE is well suited to validate SERF ablation lesion formation in real-time. The catheter tip/tissue angle impacts the lesion formation and through perpendicular catheter positioning, deeper intramural areas of the myocardium can be reached.
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Affiliation(s)
- Jannis Dickow
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic, 1216 2nd St. SW, Rochester, MN 55905, USA
| | - Songyun Wang
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic, 1216 2nd St. SW, Rochester, MN 55905, USA
| | - Atsushi Suzuki
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic, 1216 2nd St. SW, Rochester, MN 55905, USA
| | - Kimitake Imamura
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic, 1216 2nd St. SW, Rochester, MN 55905, USA
| | - H Immo Lehmann
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic, 1216 2nd St. SW, Rochester, MN 55905, USA
| | - Kay D Parker
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic, 1216 2nd St. SW, Rochester, MN 55905, USA
| | - Laura K Newman
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic, 1216 2nd St. SW, Rochester, MN 55905, USA
| | - Kristi H Monahan
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic, 1216 2nd St. SW, Rochester, MN 55905, USA
| | - Maryam E Rettmann
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic, 1216 2nd St. SW, Rochester, MN 55905, USA
| | | | - Douglas L Packer
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic, 1216 2nd St. SW, Rochester, MN 55905, USA
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Rettmann ME, Holmes DR, Monahan KH, Breen JF, Bahnson TD, Mark DB, Poole JE, Ellis AM, Silverstein AP, Al-Khalidi HR, Lee KL, Robb RA, Packer DL. Treatment-Related Changes in Left Atrial Structure in Atrial Fibrillation: Findings From the CABANA Imaging Substudy. Circ Arrhythm Electrophysiol 2021; 14:e008540. [PMID: 33848199 DOI: 10.1161/circep.120.008540] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Maryam E Rettmann
- Mayo Clinic, Rochester, MN (M.E.R., D.R.H., K.H.M., J.F.B., R.A.R., D.L.P.)
| | - David R Holmes
- Mayo Clinic, Rochester, MN (M.E.R., D.R.H., K.H.M., J.F.B., R.A.R., D.L.P.)
| | - Kristi H Monahan
- Mayo Clinic, Rochester, MN (M.E.R., D.R.H., K.H.M., J.F.B., R.A.R., D.L.P.)
| | - Jerome F Breen
- Mayo Clinic, Rochester, MN (M.E.R., D.R.H., K.H.M., J.F.B., R.A.R., D.L.P.)
| | - Tristram D Bahnson
- Duke Clinical Research Institute, Duke University, Durham, NC (T.D.B., D.B.M., A.M.E., A.P.S., H.R.A.-K., K.L.L.)
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University, Durham, NC (T.D.B., D.B.M., A.M.E., A.P.S., H.R.A.-K., K.L.L.)
| | - Jeanne E Poole
- University of Washington Medical Center, Seattle, WA (J.E.P.)
| | - Alicia M Ellis
- Duke Clinical Research Institute, Duke University, Durham, NC (T.D.B., D.B.M., A.M.E., A.P.S., H.R.A.-K., K.L.L.)
| | - Adam P Silverstein
- Duke Clinical Research Institute, Duke University, Durham, NC (T.D.B., D.B.M., A.M.E., A.P.S., H.R.A.-K., K.L.L.)
| | - Hussein R Al-Khalidi
- Duke Clinical Research Institute, Duke University, Durham, NC (T.D.B., D.B.M., A.M.E., A.P.S., H.R.A.-K., K.L.L.)
| | - Kerry L Lee
- Duke Clinical Research Institute, Duke University, Durham, NC (T.D.B., D.B.M., A.M.E., A.P.S., H.R.A.-K., K.L.L.)
| | - Richard A Robb
- Mayo Clinic, Rochester, MN (M.E.R., D.R.H., K.H.M., J.F.B., R.A.R., D.L.P.)
| | - Douglas L Packer
- Mayo Clinic, Rochester, MN (M.E.R., D.R.H., K.H.M., J.F.B., R.A.R., D.L.P.)
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Killu AM, Witt CM, Sugrue AM, Vaidya V, Monahan KH, Barnes S, Lenz CJ, Yogeswaran V, Sun PY, Hodge DO, Friedman PA, Packer DL, Asirvatham SJ. Sinus rhythm heart rate increase after atrial fibrillation ablation is associated with lower risk of arrhythmia recurrence. Pacing Clin Electrophysiol 2021; 44:651-656. [PMID: 33592679 DOI: 10.1111/pace.14197] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 02/09/2021] [Accepted: 02/14/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pulmonary vein isolation (PVI) with autonomic modulation may be more successful than PVI alone for atrial fibrillation (AF) ablation and may be signaled by changes in sinus rhythm heart rate (HR) post ablation. We sought to determine if a change in sinus rhythm HR predicted AF recurrence post PVI. METHODS Patients who underwent AF ablation from 2000 to 2011 were included if sinus rhythm was noted on ECG within 90 days pre and 7 days post ablation. Basic ECG interval and HR changes were analyzed and outcomes determined. RESULTS A total of 1152 patients were identified (74.3% male, mean age 57 ± 11 years). Mean AF duration was 5.2 ± 5.3 years. Paroxysmal AF was noted in 712 (61.8%) of the patients. Mean EF was 61% ± 6%. Sinus rhythm HR was 61 ± 11 pre-ablation and 76 ± 13 bpm post-ablation (27% ± 24% increase, p < .001). The ability of relative HR change post-ablation to predict AF recurrence was borderline (hazard ratio 0.65 [0.41-1.01], p = .067). With patients separated into quartiles based on the relative HR change, the upper quartile with the largest relative increase in HR had a significantly lower rate of AF recurrence compared to the lowest quartile following multi variable modeling (p = .038). There were significant changes in PR (171 ± 28 to 167 ± 30 ms) and QTc (424 ± 25 to 434 ± 29 ms) intervals (both p < .001) but these were not predictive of outcome. CONCLUSION Relative changes in HR post AF ablation correlates with AF recurrence. Further prospective studies are needed to confirm this relationship.
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Affiliation(s)
- Ammar M Killu
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Chance M Witt
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Alan M Sugrue
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Vaibhav Vaidya
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Kristi H Monahan
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Stephanie Barnes
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Charles J Lenz
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - David O Hodge
- Department of Health Sciences Research, Jacksonville, Florida
| | - Paul A Friedman
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Douglas L Packer
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Samuel J Asirvatham
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA.,Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota, USA
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Packer DL, Piccini JP, Monahan KH, Al-Khalidi HR, Silverstein AP, Noseworthy PA, Poole JE, Bahnson TD, Lee KL, Mark DB. Ablation Versus Drug Therapy for Atrial Fibrillation in Heart Failure: Results From the CABANA Trial. Circulation 2021; 143:1377-1390. [PMID: 33554614 DOI: 10.1161/circulationaha.120.050991] [Citation(s) in RCA: 202] [Impact Index Per Article: 67.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND In patients with heart failure and atrial fibrillation (AF), several clinical trials have reported improved outcomes, including freedom from AF recurrence, quality of life, and survival, with catheter ablation. This article describes the treatment-related outcomes of the AF patients with heart failure enrolled in the CABANA trial (Catheter Ablation Versus Antiarrhythmic Drug Therapy for Atrial Fibrillation). METHODS The CABANA trial randomized 2204 patients with AF who were ≥65 years old or <65 years old with ≥1 risk factor for stroke at 126 sites to ablation with pulmonary vein isolation or drug therapy including rate or rhythm control drugs. Of these, 778 (35%) had New York Heart Association class >II at baseline and form the subject of this article. The CABANA trial's primary end point was a composite of death, disabling stroke, serious bleeding, or cardiac arrest. RESULTS Of the 778 patients with heart failure enrolled in CABANA, 378 were assigned to ablation and 400 to drug therapy. Ejection fraction at baseline was available for 571 patients (73.0%), and 9.3% of these had an ejection fraction <40%, whereas 11.7% had ejection fractions between 40% and 50%. In the intention-to-treat analysis, the ablation arm had a 36% relative reduction in the primary composite end point (hazard ratio, 0.64 [95% CI, 0.41-0.99]) and a 43% relative reduction in all-cause mortality (hazard ratio, 0.57 [95% CI, 0.33-0.96]) compared with drug therapy alone over a median follow-up of 48.5 months. AF recurrence was decreased with ablation (hazard ratio, 0.56 [95% CI, 0.42-0.74]). The adjusted mean difference for the AFEQT (Atrial Fibrillation Effect on Quality of Life) summary score averaged over the entire 60-month follow-up was 5.0 points, favoring the ablation arm (95% CI, 2.5-7.4 points), and the MAFSI (Mayo Atrial Fibrillation-Specific Symptom Inventory) frequency score difference was -2.0 points, favoring ablation (95% CI, -2.9 to -1.2). CONCLUSIONS In patients with AF enrolled in the CABANA trial who had clinically diagnosed stable heart failure at trial entry, catheter ablation produced clinically important improvements in survival, freedom from AF recurrence, and quality of life relative to drug therapy. These results, obtained in a cohort most of whom had preserved left ventricular function, require independent trial verification. Registration: URL: https://www.clinicaltrials.gov/ct2/show/NCT00911508; Unique identifier: NCT0091150.
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Affiliation(s)
- Douglas L Packer
- Mayo Clinic Hospital, St. Marys Campus, Rochester, MN (D.L.P., K.H.M., P.A.N.)
| | - Jonathan P Piccini
- Duke Clinical Research Institute, Duke University, Durham, NC (J.P.P., H.R.A.-K., A.P.S., T.D.B., K.L.L., D.B.M.)
| | - Kristi H Monahan
- Mayo Clinic Hospital, St. Marys Campus, Rochester, MN (D.L.P., K.H.M., P.A.N.)
| | - Hussein R Al-Khalidi
- Duke Clinical Research Institute, Duke University, Durham, NC (J.P.P., H.R.A.-K., A.P.S., T.D.B., K.L.L., D.B.M.)
| | - Adam P Silverstein
- Duke Clinical Research Institute, Duke University, Durham, NC (J.P.P., H.R.A.-K., A.P.S., T.D.B., K.L.L., D.B.M.)
| | - Peter A Noseworthy
- Mayo Clinic Hospital, St. Marys Campus, Rochester, MN (D.L.P., K.H.M., P.A.N.)
| | - Jeanne E Poole
- University of Washington Medical Center, Seattle (J.E.P.)
| | - Tristram D Bahnson
- Duke Clinical Research Institute, Duke University, Durham, NC (J.P.P., H.R.A.-K., A.P.S., T.D.B., K.L.L., D.B.M.)
| | - Kerry L Lee
- Duke Clinical Research Institute, Duke University, Durham, NC (J.P.P., H.R.A.-K., A.P.S., T.D.B., K.L.L., D.B.M.)
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University, Durham, NC (J.P.P., H.R.A.-K., A.P.S., T.D.B., K.L.L., D.B.M.)
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Russo AM, Zeitler EP, Giczewska A, Silverstein AP, Al-Khalidi HR, Cha YM, Monahan KH, Bahnson TD, Mark DB, Packer DL, Poole JE. Association Between Sex and Treatment Outcomes of Atrial Fibrillation Ablation Versus Drug Therapy: Results From the CABANA Trial. Circulation 2021; 143:661-672. [PMID: 33499668 DOI: 10.1161/circulationaha.120.051558] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Among patients with atrial fibrillation (AF), women are less likely to receive catheter ablation and may have more complications and less durable results. Most information about sex-specific differences after ablation comes from observational data. We prespecified an examination of outcomes by sex in the 2204-patient CABANA trial (Catheter Ablation Versus Antiarrhythmic Drug Therapy for Atrial Fibrillation). METHODS CABANA randomized patients with AF age ≥65 years or <65 years with ≥1 risk factor for stroke to a strategy of catheter ablation with pulmonary vein isolation versus drug therapy with rate/rhythm control agents. The primary composite outcome was death, disabling stroke, serious bleeding, or cardiac arrest, and key secondary outcomes included AF recurrence. RESULTS CABANA randomized 819 (37%) women (ablation 413, drug 406) and 1385 men (ablation 695, drug 690). Compared with men, women were older (median age, 69 years versus 67 years for men), were more symptomatic (48% Canadian Cardiovascular Society AF Severity Class 3 or 4 versus 39% for men), had more symptomatic heart failure (42% with New York Heart Association Class ≥II versus 32% for men), and more often had a paroxysmal AF pattern at enrollment (50% versus 39% for men) (P<0.0001 for all). Women were less likely to have ancillary (nonpulmonary vein) ablation procedures performed during the index procedure (55.7% versus 62.2% in men, P=0.043), and complications from treatment were infrequent in both sexes. For the primary outcome, the hazard ratio for those who underwent ablation versus drug therapy was 1.01 (95% CI, 0.62-1.65) in women and 0.73 (95% CI, 0.51-1.05) in men (interaction P value=0.299). The risk of recurrent AF was significantly reduced in patients undergoing ablation compared with those receiving drug therapy regardless of sex, but the effect was greater in men (hazard ratio, 0.64 [95% CI, 0.51-0.82] for women versus hazard ratio, 0.48 [95% CI, 0.40-0.58] for men; interaction P value=0.060). CONCLUSIONS Clinically relevant treatment-related strategy differences in the primary and secondary clinical outcomes of CABANA were not seen between men and women, and there were no sex differences in adverse events. The CABANA trial results support catheter ablation as an effective treatment strategy for both women and men. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT00911508.
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Affiliation(s)
- Andrea M Russo
- Division of Cardiovascular Disease, Cooper Medical School of Rowan University, Camden, NJ (A.M.R.)
| | - Emily P Zeitler
- The Geisel School of Medicine at Dartmouth, Hanover, NH, Division of Cardiology, Dartmouth-Hitchcock Medical Center, and The Dartmouth Institute, Lebanon, NH (E.P.Z.)
| | - Anna Giczewska
- Duke Clinical Research Institute, Duke University, Durham, NC (A.G., A.P.S., H.R.A.-K., T.D.B., D.B.M.)
| | - Adam P Silverstein
- Duke Clinical Research Institute, Duke University, Durham, NC (A.G., A.P.S., H.R.A.-K., T.D.B., D.B.M.)
| | - Hussein R Al-Khalidi
- Duke Clinical Research Institute, Duke University, Durham, NC (A.G., A.P.S., H.R.A.-K., T.D.B., D.B.M.)
| | - Yong-Mei Cha
- Mayo Clinic, St Mary's Campus, Rochester, MN (Y.-M.C., K.H.M., D.L.P.)
| | - Kristi H Monahan
- Mayo Clinic, St Mary's Campus, Rochester, MN (Y.-M.C., K.H.M., D.L.P.)
| | - Tristram D Bahnson
- Duke Clinical Research Institute, Duke University, Durham, NC (A.G., A.P.S., H.R.A.-K., T.D.B., D.B.M.)
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University, Durham, NC (A.G., A.P.S., H.R.A.-K., T.D.B., D.B.M.)
| | - Douglas L Packer
- Mayo Clinic, St Mary's Campus, Rochester, MN (Y.-M.C., K.H.M., D.L.P.)
| | - Jeanne E Poole
- University of Washington Medical Center, Seattle (J.E.P.)
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Poole JE, Olshansky B, Mark DB, Anderson J, Johnson G, Hellkamp AS, Davidson-Ray L, Fishbein DP, Boineau RE, Anstrom KJ, Reinhall PG, Packer DL, Lee KL, Bardy GH. Long-Term Outcomes of Implantable Cardioverter-Defibrillator Therapy in the SCD-HeFT. J Am Coll Cardiol 2021; 76:405-415. [PMID: 32703511 DOI: 10.1016/j.jacc.2020.05.061] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 05/24/2020] [Accepted: 05/28/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND The SCD-HeFT (Sudden Cardiac Death in Heart Failure Trial) randomized 2,521 patients with moderate heart failure (HF) to amiodarone, placebo drug, or implantable cardioverter-defibrillator (ICD) therapy. Original trial follow-up ended October 31, 2003. Over a median 45.5-month follow-up, amiodarone, compared with placebo, did not affect survival, whereas randomization to an ICD significantly decreased all-cause mortality by 23%. OBJECTIVES This study sought to describe the extended treatment group survival of the SCD-HeFT cohort. METHODS Mortality outcomes for the 1,855 patients alive at the end of the SCD-HeFT trial were collected between 2010 and 2011. These data were combined with the 666 deaths from the original study to compare long-term outcomes overall and for key pre-specified subgroups. RESULTS Median (25th to 75th percentiles) follow-up was 11.0 (10.0 to 12.2) years. On the basis of intention-to-treat analysis, the ICD group had overall survival benefit versus placebo drug (hazard ratio [HR]: 0.87; 95% confidence interval [CI]: 0.76 to 0.98; p = 0.028). When treatment benefit was examined as a function of time from randomization, attenuation of the ICD benefit was observed after 6 years (p value for the interaction = 0.0015). Subgroup analysis revealed long-term ICD benefit varied according to HF etiology and New York Heart Association (NYHA) functional class: ischemic HF HR: 0.81; 95% CI: 0.69 to 0.95; p = 0.009; nonischemic HF HR: 0.97; 95% CI: 0.79 to 1.20; p = 0.802; NYHA functional class II HR: 0.76; 95% CI: 0.65 to 0.90; p = 0.001; NYHA functional class III HR: 1.06; 95% CI: 0.86 to 1.31; p = 0.575. CONCLUSIONS Follow-up of SCD-HeFT patients to 11 years demonstrated heterogenous treatment-related patterns of long-term survival with ICD benefit most evident at 11 years for ischemic HF patients and for those with NYHA functional class II symptoms at trial enrollment. (SCD-HeFT 10 Year Follow-up [SCD-HeFT10 Yr]; NCT01058837).
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Affiliation(s)
- Jeanne E Poole
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington.
| | - Brian Olshansky
- Department of Medicine, Division of Cardiology, University of Iowa, Iowa City, Iowa
| | - Daniel B Mark
- Department of Medicine, Division of Cardiology, Duke University, Durham, North Carolina
| | - Jill Anderson
- Seattle Institute for Cardiac Research, Seattle, Washington
| | - George Johnson
- Seattle Institute for Cardiac Research, Seattle, Washington
| | - Anne S Hellkamp
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Linda Davidson-Ray
- Department of Medicine, Division of Cardiology, Duke University, Durham, North Carolina
| | - Daniel P Fishbein
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington
| | - Robin E Boineau
- National Center for Complementary and Integrative Health, National institutes of Health, Bethesda, Maryland
| | - Kevin J Anstrom
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Per G Reinhall
- Department of Mechanical Engineering, University of Washington, Seattle, Washington
| | - Douglas L Packer
- Department of Cardiology, Division of Cardiac Electrophysiology, Mayo Clinic, Rochester, Minnesota
| | - Kerry L Lee
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Gust H Bardy
- Department of Medicine, Division of Cardiology, Seattle Institute for Cardiac Research, Seattle, Washington
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Hohmann S, Deisher AJ, Konishi H, Rettmann ME, Suzuki A, Merrell KW, Kruse JJ, Fitzgerald ST, Newman LK, Parker KD, Monahan KH, Foote RL, Herman MG, Packer DL. Catheter-free ablation of infarct scar through proton beam therapy: Tissue effects in a porcine model. Heart Rhythm 2020; 17:2190-2199. [DOI: 10.1016/j.hrthm.2020.07.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/06/2020] [Accepted: 07/09/2020] [Indexed: 12/19/2022]
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Calkins H, Gache L, Frame D, Boo LM, Ghaly N, Schilling R, Deering T, Duytschaever M, Packer DL. Predictive value of atrial fibrillation during the postradiofrequency ablation blanking period. Heart Rhythm 2020; 18:366-373. [PMID: 33242668 DOI: 10.1016/j.hrthm.2020.11.020] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 10/30/2020] [Accepted: 11/16/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Recurrent arrhythmia following catheter ablation of atrial fibrillation (AF) may present early, during a standard 3-month blanking period. Early recurrence has been correlated to late recurrence, but the degree to which its absence predicts longer-term success has not been quantified. OBJECTIVE The purpose of this study was to explore and quantify the relationship between early and late arrhythmia recurrence, specifically the negative predictive value, that is, the degree to which absence of blanking period recurrence predicts absence of late recurrence. METHODS A systematic literature review and meta-analysis were conducted using statistical methods of a diagnostic test accuracy review. Studies of AF ablation using point-by-point radiofrequency, with repeated monitoring of arrhythmia recurrence including asymptomatic recurrence, and with separate data by AF type, were eligible. RESULTS Nine studies met the prespecified eligibility criteria. For paroxysmal AF, 89% (confidence interval [CI] 82%-94%) of patients free from early recurrence remained free from late recurrence. The estimate for persistent AF was similar (91%; CI 75%-97%). This finding was robust in sensitivity analyses. Patients with early recurrence had a wider range of likely outcomes with longer-term follow-up. CONCLUSION Freedom from AF recurrence during the blanking period is highly predictive of longer-term success in catheter ablation. Clinical trials in this area may be able to leverage these findings to more quickly assess the potential utility of new ablation technologies and methods, for example, by using early surrogate measures of success.
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Affiliation(s)
- Hugh Calkins
- Department of Cardiology, Johns Hopkins Medical Institutions, Baltimore, Maryland.
| | - Larry Gache
- Real World Evidence, CTI Clinical Trial and Consulting Services, Covington, Kentucky
| | - Diana Frame
- Real World Evidence, CTI Clinical Trial and Consulting Services, Covington, Kentucky
| | - Lee Ming Boo
- Clinical Science and External Research, Biosense Webster, Inc, Irvine, California
| | - Nader Ghaly
- Medical Affairs, Biosense Webster, Inc, Irvine, California
| | - Richard Schilling
- Department of Cardiology, St Bartholomew's Hospital, London, United Kingdom
| | - Thomas Deering
- Department of Cardiology, Piedmont Heart Institute, Atlanta, Georgia
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Dickow J, Suzuki A, Henz BD, Madhavan M, Lehmann HI, Wang S, Parker KD, Monahan KH, Rettmann ME, Curley MG, Packer DL. Characterization of Lesions Created by a Heated, Saline Irrigated Needle-Tip Catheter in the Normal and Infarcted Canine Heart. Circ Arrhythm Electrophysiol 2020; 13:e009090. [PMID: 33198498 DOI: 10.1161/circep.120.009090] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Inability to eliminate intramural arrhythmogenic substrate may lead to recurrent ventricular tachycardia after catheter ablation. The aim of the present study was to evaluate intramural and full thickness lesion formation using a heated saline-enhanced radiofrequency (SERF) needle-tip catheter, compared with a conventional ablation catheter in normal and infarcted myocardium. METHODS Twenty-two adult mongrel dogs (30-40 kg, 15 normal and 7 myocardial infarct group) were studied. Lesions were created using the SERF catheter (40 W/50 °C) or a standard contact force (CF) catheter in both groups. RESULTS Comparing SERF to CF ablation, the SERF catheter produced larger lesion volumes than the standard CF catheter-even with >20 g of CF-in both normal (983.1±905.8 versus 461.9±178.3 mm3; P=0.023) and infarcted left ventricular myocardium (1052.3±543.0 versus 340.3±160.5 mm3; P=0.001). SERF catheter lesions were more often transmural than standard CF lesions with >20 g of CF in both groups (59.1% versus 7.7%; P<0.001 and 60.0% versus 12.5%; P=0.017, respectively). Using the SERF catheter, mean depth of ablated lesions reached 90% of the left ventricular wall in both normal and infarcted myocardium. CONCLUSIONS The SERF catheter created more transmural and larger ablative lesions in both normal and infarcted canine myocardium. SERF ablation is a promising new approach for endocardial intramural and full thickness ablation of ventricular tachycardia substrate that is not accessible with current techniques.
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Affiliation(s)
- Jannis Dickow
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic, Rochester, MN (J.D., A.S., B.D.H., M.M., H.I.L., S.W., K.D.P., K.H.M., M.E.R., D.L.P.)
| | - Atsushi Suzuki
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic, Rochester, MN (J.D., A.S., B.D.H., M.M., H.I.L., S.W., K.D.P., K.H.M., M.E.R., D.L.P.)
| | - Benhur D Henz
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic, Rochester, MN (J.D., A.S., B.D.H., M.M., H.I.L., S.W., K.D.P., K.H.M., M.E.R., D.L.P.)
| | - Malini Madhavan
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic, Rochester, MN (J.D., A.S., B.D.H., M.M., H.I.L., S.W., K.D.P., K.H.M., M.E.R., D.L.P.)
| | - H Immo Lehmann
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic, Rochester, MN (J.D., A.S., B.D.H., M.M., H.I.L., S.W., K.D.P., K.H.M., M.E.R., D.L.P.)
| | - Songyun Wang
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic, Rochester, MN (J.D., A.S., B.D.H., M.M., H.I.L., S.W., K.D.P., K.H.M., M.E.R., D.L.P.)
| | - Kay D Parker
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic, Rochester, MN (J.D., A.S., B.D.H., M.M., H.I.L., S.W., K.D.P., K.H.M., M.E.R., D.L.P.)
| | - Kristi H Monahan
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic, Rochester, MN (J.D., A.S., B.D.H., M.M., H.I.L., S.W., K.D.P., K.H.M., M.E.R., D.L.P.)
| | - Maryam E Rettmann
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic, Rochester, MN (J.D., A.S., B.D.H., M.M., H.I.L., S.W., K.D.P., K.H.M., M.E.R., D.L.P.)
| | | | - Douglas L Packer
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic, Rochester, MN (J.D., A.S., B.D.H., M.M., H.I.L., S.W., K.D.P., K.H.M., M.E.R., D.L.P.)
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Shabtaie SA, Luis SA, Ward RC, Karki R, Connolly HM, Pellikka PA, Kapa S, Asirvatham SJ, Packer DL, DeSimone CV. Catheter Ablation in Patients With Neuroendocrine (Carcinoid) Tumors and Carcinoid Heart Disease: Outcomes, Peri-Procedural Complications, and Management Strategies. JACC Clin Electrophysiol 2020; 7:151-160. [PMID: 33602395 DOI: 10.1016/j.jacep.2020.08.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 07/30/2020] [Accepted: 08/03/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES This report describes a series of patients with neuroendocrine tumors with or without carcinoid heart disease undergoing catheter ablation at the authors' institution. BACKGROUND Neuroendocrine (carcinoid) tumors are a rare form of neoplasm with the potential for systemic vasoactive effects and cardiac valvular involvement. These tumors can create peri-operative management challenges for the electrophysiologist. However, there are few data regarding ablation outcomes, periprocedural complications, and management of these patients. METHODS All patients with neuroendocrine tumors undergoing catheter ablation at the Mayo Clinic, Rochester, Minnesota over a 25-year period were retrospectively reviewed. From this cohort, the type of arrhythmias ablated, the recurrence of arrhythmia, perioperative complications, and mortality were reviewed and analyzed. RESULTS A total of 17 patients (52.9% male; mean age 62.4 ± 9.3 years) with neuroendocrine tumors underwent catheter ablation during the study period. Primary tumor sites included the gastrointestinal tract (n = 11), lung (n = 4), ovary (n = 1), and lymph node (n = 1). Nine patients had metastatic disease, 5 of whom were on somatostatin analog therapy at the time of ablation. Three patients had active symptoms of carcinoid syndrome at the time of ablation, and 2 of those patients had carcinoid heart disease. Ablations were performed mainly for atrial arrhythmias (76.5%): atrioventricular nodal re-entry tachycardia (n = 7), atrial fibrillation (n = 4), and atrial flutter (n = 2). Four patients underwent ablation of ventricular arrhythmias. During a mean follow-up of 19.2 ± 26.2 months, arrhythmia recurred in 35.3% of patients. Three patients (17.6%) had periprocedural complications: pericardial effusion (n = 1), groin site hematoma (n = 1), and carcinoid crisis (n = 1). No deaths were noted in the peri-operative period. CONCLUSIONS In a unique cohort of patients with neuroendocrine tumors, catheter ablation was feasible in patients with or without carcinoid syndrome. Carcinoid crisis may occur during the periprocedural period, which can be life-threatening, and a specified protocol for management is important to mitigate this risk.
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Affiliation(s)
| | - Sushil Allen Luis
- Division of Cardiovascular Disease, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Robert C Ward
- Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Roshan Karki
- Division of Cardiovascular Disease, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Heidi M Connolly
- Division of Cardiovascular Disease, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Patricia A Pellikka
- Division of Cardiovascular Disease, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Suraj Kapa
- Division of Cardiovascular Disease, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Samuel J Asirvatham
- Division of Cardiovascular Disease, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Douglas L Packer
- Division of Cardiovascular Disease, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Christopher V DeSimone
- Division of Cardiovascular Disease, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA.
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Suzuki A, Deisher AJ, Rettmann ME, Lehmann HI, Hohmann S, Wang S, Konishi H, Kruse JJ, Cusma JT, Newman LK, Parker KD, Monahan KH, Herman MG, Packer DL. Catheter-Free Arrhythmia Ablation Using Scanned Proton Beams: Electrophysiologic Outcomes, Biophysics, and Characterization of Lesion Formation in a Porcine Model. Circ Arrhythm Electrophysiol 2020; 13:e008838. [PMID: 32921132 DOI: 10.1161/circep.120.008838] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Proton beam therapy offers radiophysical properties that are appealing for noninvasive arrhythmia elimination. This study was conducted to use scanned proton beams for ablation of cardiac tissue, investigate electrophysiological outcomes, and characterize the process of lesion formation in a porcine model using particle therapy. METHODS Twenty-five animals received scanned proton beam irradiation. ECG-gated computed tomography scans were acquired at end-expiration breath hold. Structures (atrioventricular junction or left ventricular myocardium) and organs at risk were contoured. Doses of 30, 40, and 55 Gy were delivered during expiration to the atrioventricular junction (n=5) and left ventricular myocardium (n=20) of intact animals. RESULTS In this study, procedural success was tracked by pacemaker interrogation in the atrioventricular junction group, time-course magnetic resonance imaging in the left ventricular group, and correlation of lesion outcomes displayed in gross and microscopic pathology. Protein extraction (active caspase-3) was performed to investigate tissue apoptosis. Doses of 40 and 55 Gy caused slowing and interruption of cardiac impulse propagation at the atrioventricular junction. In 40 left ventricular irradiated targets, all lesions were identified on magnetic resonance after 12 weeks, being consistent with outcomes from gross pathology. In the majority of cases, lesion size plateaued between 12 and 16 weeks. Active caspase-3 was seen in lesions 12 and 16 weeks after irradiation but not after 20 weeks. CONCLUSIONS Scanned proton beams can be used as a tool for catheter-free ablation, and time-course of tissue apoptosis was consistent with lesion maturation.
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Affiliation(s)
- Atsushi Suzuki
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic/St. Marys Campus, Rochester, MN (A.S., M.E.R., H.I.L., S.H., S.W., H.K., L.K.N., K.D.P., K.H.M., D.L.P.)
| | - Amanda J Deisher
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN (A.J.D., J.J.K., J.T.C., M.G.H.)
| | - Maryam E Rettmann
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic/St. Marys Campus, Rochester, MN (A.S., M.E.R., H.I.L., S.H., S.W., H.K., L.K.N., K.D.P., K.H.M., D.L.P.)
| | - H Immo Lehmann
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic/St. Marys Campus, Rochester, MN (A.S., M.E.R., H.I.L., S.H., S.W., H.K., L.K.N., K.D.P., K.H.M., D.L.P.).,Department of Cardiology, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston (H.I.L.).,Harvard Medical School, Boston, MA (H.I.L.)
| | - Stephan Hohmann
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic/St. Marys Campus, Rochester, MN (A.S., M.E.R., H.I.L., S.H., S.W., H.K., L.K.N., K.D.P., K.H.M., D.L.P.)
| | - Songyun Wang
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic/St. Marys Campus, Rochester, MN (A.S., M.E.R., H.I.L., S.H., S.W., H.K., L.K.N., K.D.P., K.H.M., D.L.P.)
| | - Hiroki Konishi
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic/St. Marys Campus, Rochester, MN (A.S., M.E.R., H.I.L., S.H., S.W., H.K., L.K.N., K.D.P., K.H.M., D.L.P.)
| | - Jon J Kruse
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN (A.J.D., J.J.K., J.T.C., M.G.H.)
| | - Jack T Cusma
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN (A.J.D., J.J.K., J.T.C., M.G.H.)
| | - Laura K Newman
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic/St. Marys Campus, Rochester, MN (A.S., M.E.R., H.I.L., S.H., S.W., H.K., L.K.N., K.D.P., K.H.M., D.L.P.)
| | - Kay D Parker
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic/St. Marys Campus, Rochester, MN (A.S., M.E.R., H.I.L., S.H., S.W., H.K., L.K.N., K.D.P., K.H.M., D.L.P.)
| | - Kristi H Monahan
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic/St. Marys Campus, Rochester, MN (A.S., M.E.R., H.I.L., S.H., S.W., H.K., L.K.N., K.D.P., K.H.M., D.L.P.)
| | - Michael G Herman
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN (A.J.D., J.J.K., J.T.C., M.G.H.)
| | - Douglas L Packer
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic/St. Marys Campus, Rochester, MN (A.S., M.E.R., H.I.L., S.H., S.W., H.K., L.K.N., K.D.P., K.H.M., D.L.P.)
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Noseworthy PA, Gersh BJ, Kent DM, Piccini JP, Packer DL, Shah ND, Yao X. Atrial fibrillation ablation in practice: assessing CABANA generalizability. Eur Heart J 2020; 40:1257-1264. [PMID: 30875424 DOI: 10.1093/eurheartj/ehz085] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 05/16/2018] [Accepted: 02/11/2019] [Indexed: 01/19/2023] Open
Abstract
AIMS The Catheter Ablation vs. Antiarrhythmic Drug Therapy for Atrial Fibrillation (CABANA) trial aimed to assess the impact of ablation on morbidity and mortality. This observational study was conducted in parallel to CABANA to assess trial generalizability. METHODS AND RESULTS Using a large US administrative database, we identified 183 760 patients with atrial fibrillation (AF) treated with ablation or medical therapy (antiarrhythmic or rate control drugs) between 1 August 2009 and 30 April 2016 (CABANA enrolment period). Propensity score weighting was used to balance patients treated with ablation (N = 12 032) or medical therapy alone (N = 171 728) on 90 dimensions. Ablation was associated with a reduction in the composite endpoint of all-cause mortality, stroke, major bleeding, and cardiac arrest [hazard ratio (HR) 0.75, 95% confidence interval (CI) 0.70-0.81; P < 0.001]. The majority of patients (73.8%) were potentially trial eligible; among whom the risk reduction associated with ablation was greatest (HR 0.70, 95% CI 0.63-0.77; P < 0.001). Among the 3.8% of patients who failed to meet the inclusion criterion, i.e. patients under 65 years without stroke risk factors, the event rates were low and there was no significant relationship with ablation (HR 0.67, 95% CI 0.29-1.56; P = 0.35). Among the 22.4% patients who met at least one of the trial exclusion criteria, there was a lesser but statistically significant reduction associated with ablation (HR 0.85, 95% CI 0.75-0.95; P = 0.01). CONCLUSION In routine clinical care, ablation was associated with a reduction in the primary CABANA composite endpoint of all-cause mortality, stroke, major bleeding, and cardiac arrest, particularly in patients who were eligible for the trial.
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Affiliation(s)
- Peter A Noseworthy
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, 200 1st St SW, Rochester, MN, USA.,Department of Cardiovascular Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN, USA
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN, USA
| | - David M Kent
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center/Tufts University School of Medicine, 800 Washington St, Boston, MA, USA.,Department of Neurology, Tufts Medical Center/Tufts University School of Medicine, 800 Washington St, Boston, MA, USA
| | - Jonathan P Piccini
- Duke Center for Atrial Fibrillation, Duke Clinical Research Institute, Duke University Medical Center, 2400 Pratt St, Durham, NC, USA
| | - Douglas L Packer
- Department of Cardiovascular Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN, USA
| | - Nilay D Shah
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, 200 1st St SW, Rochester, MN, USA.,Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, 205 3rd Ave SW, Rochester, MN, USA.,OptumLabs, One Main Street, 10th Floor, Cambridge, MA, USA
| | - Xiaoxi Yao
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, 200 1st St SW, Rochester, MN, USA.,Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, 205 3rd Ave SW, Rochester, MN, USA
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Noseworthy PA, Van Houten HK, Gersh BJ, Packer DL, Friedman PA, Shah ND, Dunlay SM, Siontis KC, Piccini JP, Yao X. Generalizability of the CASTLE-AF trial: Catheter ablation for patients with atrial fibrillation and heart failure in routine practice. Heart Rhythm 2020; 17:1057-1065. [PMID: 32145348 PMCID: PMC7648571 DOI: 10.1016/j.hrthm.2020.02.030] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 02/24/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND In the Catheter Ablation for Atrial Fibrillation with Heart Failure (CASTLE-AF) trial, catheter ablation reduced the risk of death and heart failure (HF) hospitalization in patients with atrial fibrillation and HF by 40%. OBJECTIVES The study aimed to assess the generalizability of CASTLE-AF to routine clinical practice. METHODS Using a large US administrative database, we identified 289,831 patients with atrial fibrillation and HF treated with ablation (n = 7465) or medical therapy alone (n = 282,366) from January 1, 2008, through August 31, 2018. Patients were divided into 3 groups on the basis of trial eligibility: (1) eligible for CASTLE-AF, (2) failing to meet the inclusion criteria, and (3) meeting at least 1 of the exclusion criteria. Propensity score overlap weighting was used to balance ablated and drug-treated patients on 90 baseline characteristics. Cox proportional hazards regression was used to compare ablation with medical therapy for the primary outcome of a composite end point of all-cause mortality and HF hospitalization. RESULTS Only 7.8% of patients would have been eligible for the trial; 91.0% failed to meet the trial inclusion criteria; and 15.5% met the exclusion criteria. Ablation was associated with a lower risk of the primary outcome in the overall cohort (hazard ratio [HR] 0.81; 95% confidence interval [CI] 0.76-0.87; P < .001), in the trial-eligible cohort (HR 0.82; 95% CI 0.70-0.96; P = .01), and in patients who failed to meet inclusion criteria (HR 0.79; 95% CI 0.73-0.86; P < .001) but not in patients who met the exclusion criteria (HR 0.97; 95% CI 0.81-1.17). The relative risk reduction was consistent regardless of whether patients had HF with reduced left ventricular ejection fraction. CONCLUSION The benefit associated with ablation appears to be more modest in practice than that reported in the CASTLE-AF trial.
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Affiliation(s)
- Peter A Noseworthy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Holly K Van Houten
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Douglas L Packer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Paul A Friedman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Nilay D Shah
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota; Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota; OptumLabs, Cambridge, Massachusetts
| | - Shannon M Dunlay
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Jonathan P Piccini
- Duke Center for Atrial Fibrillation, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Xiaoxi Yao
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota.
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Poole JE, Bahnson TD, Monahan KH, Johnson G, Rostami H, Silverstein AP, Al-Khalidi HR, Rosenberg Y, Mark DB, Lee KL, Packer DL. Recurrence of Atrial Fibrillation After Catheter Ablation or Antiarrhythmic Drug Therapy in the CABANA Trial. J Am Coll Cardiol 2020; 75:3105-3118. [PMID: 32586583 PMCID: PMC8064404 DOI: 10.1016/j.jacc.2020.04.065] [Citation(s) in RCA: 101] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 03/09/2020] [Accepted: 04/21/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND The CABANA (Catheter Ablation Versus Antiarrhythmic Drug Therapy for Atrial Fibrillation) trial randomized 2,204 patients with atrial fibrillation (AF) to catheter ablation or drug therapy. Analysis by intention-to-treat showed a nonsignificant 14% relative reduction in the primary outcome of death, disabling stroke, serious bleeding, or cardiac arrest. OBJECTIVES The purpose of this study was to assess recurrence of AF in the CABANA trial. METHODS The authors prospectively studied CABANA patients using a proprietary electrocardiogram recording monitor for symptom-activated and 24-h AF auto detection. The AF recurrence endpoint was any post-90-day blanking atrial tachyarrhythmias lasting 30 s or longer. Biannual 96-h Holter monitoring was used to assess AF burden. Patients who used the CABANA monitors and provided 90-day post-blanking recordings qualified for this analysis (n = 1,240; 56% of CABANA population). Treatment comparisons were performed using a modified intention-to-treat approach. RESULTS Median age of the 1,240 patients was 68 years, 34.4% were women, and AF was paroxysmal in 43.0%. Over 60 months of follow-up, first recurrence of any symptomatic or asymptomatic AF (hazard ratio: 0.52; 95% confidence interval: 0.45 to 0.60; p < 0.001) or first symptomatic-only AF (hazard ratio: 0.49; 95% confidence interval: 0.39 to 0.61; p < 0.001) were both significantly reduced in the catheter ablation group. Baseline Holter AF burden in both treatment groups was 48%. At 12 months, AF burden in ablation patients averaged 6.3%, and in drug-therapy patients, 14.4%. AF burden was significantly less in catheter ablation compared with drug-therapy patients across the 5-year follow-up (p < 0.001). These findings were not sensitive to the baseline pattern of AF. CONCLUSIONS Catheter ablation was effective in reducing recurrence of any AF by 48% and symptomatic AF by 51% compared with drug therapy over 5 years of follow-up. Furthermore, AF burden was also significantly reduced in catheter ablation patients, regardless of their baseline AF type. (Catheter Ablation vs Anti-arrhythmic Drug Therapy for Atrial Fibrillation Trial [CABANA]; NCT00911508).
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Affiliation(s)
- Jeanne E Poole
- University of Washington Medical Center, Seattle, Washington.
| | - Tristram D Bahnson
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | | | - George Johnson
- Seattle Institute of Cardiac Research, Seattle, Washington
| | - Hoss Rostami
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Adam P Silverstein
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | | | - Yves Rosenberg
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Kerry L Lee
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
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Suzuki A, Lehmann HI, Wang S, Parker KD, Rettmann ME, Monahan KH, Packer DL. Biophysical properties, efficacy, and lesion characteristics of a new linear cryoablation catheter in a canine model. Heart Rhythm 2020; 17:1967-1975. [PMID: 32470624 DOI: 10.1016/j.hrthm.2020.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/18/2020] [Accepted: 05/19/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND The cryoballoon (CB) catheter is an established tool for pulmonary vein isolation (PVI), but its use is limited for that purpose. OBJECTIVE The purpose of this study was to investigate the biophysical properties of a newly developed linear cryoablation catheter for creation of linear ablation lesions in an in vivo model. METHODS Twenty-nine dogs (14 acutely ablated, 15 chronically followed) underwent cryoablation using the linear cryoablation catheter. Regions of interest included the cavotricuspid isthmus (CTI), mitral isthmus (MI), left atrial (LA) roof, and LA posterior wall in an acute study. Cryoablations for CTI and MI were performed in 14 atrial fibrillation animals after PVI and followed over 1 month in the chronic study. Tissue temperature during cryoablation was monitored using implanted thermocouples in the regions of interest. Gross and microscopic pathologic characteristics of the lesions were assessed. RESULTS In acute animals, lesion length (transmurality) was CTI 34 ± 4 mm (89% ± 11%); MI 29 ± 4 mm (90% ± 13%); LA roof 19 ± 3 mm (90% ± 8%); and LA posterior wall 19 ± 2 mm (81% ± 13%), with 1 or 2 freezes. Chronic bidirectional block was achieved in 13 of 14 CTI (93%) and 10 of 14 MI (71%) ablations after 1-month follow-up and was consistent with lesion continuity and transmurality upon pathology. The lowest tissue temperature correlated well with the closest distance to the linear cryocatheter (r = 0.688; P <.001). CONCLUSION This linear cryocatheter created continuous and transmural linear lesions with "single-shot" cryoenergy application and has the potential for clinical use in the setting of various arrhythmias.
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Affiliation(s)
- Atsushi Suzuki
- Mayo Clinic/St. Marys Campus, Rochester, Minnesota; Osaka Saiseikai Nakatsu Hospital, Osaka, Japan
| | - H Immo Lehmann
- Mayo Clinic/St. Marys Campus, Rochester, Minnesota; Massachusetts General Hospital, Corrigan Minehan Heart Center, Boston, Massachusetts
| | - Songyun Wang
- Mayo Clinic/St. Marys Campus, Rochester, Minnesota; Renmin Hospital of Wuhan University, Wuhan, China
| | - Kay D Parker
- Mayo Clinic/St. Marys Campus, Rochester, Minnesota
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Fender EA, Widmer RJ, Mahowald MK, Hodge DO, Packer DL, Holmes DR. Recurrent pulmonary vein stenosis after successful intervention: Prognosis and management of restenosis. Catheter Cardiovasc Interv 2020; 95:954-958. [PMID: 31854110 DOI: 10.1002/ccd.28645] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/15/2019] [Accepted: 12/07/2019] [Indexed: 12/31/2022]
Abstract
OBJECTIVES The aim of this study was to describe management of recurrent pulmonary vein stenosis (PVS) and determine if stenting is superior to balloon angioplasty (BA) in preventing subsequent restenosis. BACKGROUND PVS is a serious complication of atrial fibrillation ablation. BA and stenting are effective therapies; however, restenosis frequently occurs. Here we report management of recurrent stenosis. METHODS This was a prospective observational study performed from 2000 to 2014. RESULTS One hundred and thirteen patients with severe PVS underwent intervention in 88 veins treated with BA and 81 treated with stenting. Forty-two patients experienced restenosis. Restenosis was more common in veins treated with BA (RRR 53% [95% CI 32-70%, p = .008]). A second intervention was performed in 41 patients. In the 34 vessels treated with initial BA, 24 were treated for restenosis with a stent and 10 were treated with a second BA. The recurrence rate was 46% in those treated with BA followed by stenting and 50% in those treated with two BA procedures. In the 22 veins treated with initial stenting, 9 were treated with another stent and 13 were treated with BA. The recurrence rate was 44% in those treated with a second stent and 46% for those treated with a stent followed by BA. The risk of a third stenosis was the same among all groups (Analysis of variance [ANOVA] p = .99). Limited sample size precluded analysis of outcome by stent size. CONCLUSIONS Restenosis occurred in 44% of patients overall. Management is challenging; stenting does not appear to be superior to BA.
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Affiliation(s)
- Erin A Fender
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - R Jay Widmer
- Department of Internal Medicine, Division of Cardiovascular Diseases, Baylor Scott and White, Temple, Texas
| | | | - David O Hodge
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, Florida
| | - Douglas L Packer
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - David R Holmes
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
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Hermida JS, Chen J, Meyer C, Iacopino S, Arena G, Pavlovic N, Velagic V, Healey S, Packer DL, Pitschner HF, de Asmundis C, Kuniss M, Chierchia GB. Cryoballoon catheter ablation versus antiarrhythmic drugs as a first-line therapy for patients with paroxysmal atrial fibrillation: Rationale and design of the international Cryo-FIRST study. Am Heart J 2020; 222:64-72. [PMID: 32018203 DOI: 10.1016/j.ahj.2019.12.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 12/06/2019] [Indexed: 01/15/2023]
Abstract
BACKGROUND Radiofrequency current (RFC) catheter ablation for patients with paroxysmal atrial fibrillation (AF) has been shown to be safe and effective in first-line therapy. Recent data demonstrates that RFC ablation provides better clinical outcomes compared to antiarrhythmic drug (AAD) in the treatment of early AF disease. Furthermore, studies comparing RFC and cryoballoon have established comparable efficacy and safety of pulmonary vein isolation (PVI) for patients with symptomatic paroxysmal AF. OBJECTIVES The Cryo-FIRST trial was designed to compare AAD treatment against cryoballoon PVI as a first-line therapy in treatment naïve patients with AF. Efficacy and safety will be compared between the two cohorts and amongst subgroups. METHODS The primary hypothesis is that cryoablation is superior to AAD therapy. To test this hypothesis, patients will be randomized in a 1:1 design. Using a 90-day blanking period, primary efficacy endpoint failure is defined as (at least) one episode of atrial arrhythmia with a duration >30 sec (documented by 7-day Holter or 12-lead ECG). Secondary endpoints (Quality-of-Life, rehospitalization, arrhythmia recurrence rate, healthcare utilization, and left atrial function) and adverse events will also be evaluated. Study enrollment will include 218 patients in up to 16 centers. CONCLUSIONS This study will be a multi-national randomized controlled trial comparing cryoablation against AAD as a first-line treatment in patients with paroxysmal AF. The results may help guide the selection of patients for early AF disease therapy via cryoballoon ablation.
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Affiliation(s)
| | - Jian Chen
- Haukeland University Hospital, Bergen, NO
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Chew DS, Black-Maier E, Loring Z, Noseworthy PA, Packer DL, Exner DV, Mark DB, Piccini JP. Diagnosis-to-Ablation Time and Recurrence of Atrial Fibrillation Following Catheter Ablation: A Systematic Review and Meta-Analysis of Observational Studies. Circ Arrhythm Electrophysiol 2020; 13:e008128. [PMID: 32191539 DOI: 10.1161/circep.119.008128] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND The optimal timing of catheter ablation for atrial fibrillation (AF) in reference to the time of diagnosis is unknown. We sought to assess the impact of the duration between first diagnosis of AF and ablation, or diagnosis-to-ablation time (DAT), on AF recurrence following catheter ablation. METHODS We conducted a systematic electronic search for observational studies reporting the outcomes associated with catheter ablation for atrial fibrillation stratified by diagnosis-to-ablation time. The primary meta-analysis using a random effects model assessed AF recurrence stratified by DAT ≤1 year versus >1 year. A secondary analysis assessed outcomes stratified by DAT ≤3 years versus >3 years. RESULTS Of the 632 screened studies, 6 studies met inclusion criteria for a total of 4950 participants undergoing AF ablation for symptomatic AF. A shorter DAT ≤1 year was associated with a lower relative risk of AF recurrence compared with DAT >1 year (relative risk, 0.73 [95% CI, 0.65-0.82]; P<0.001). Heterogeneity was moderate (I2=51%). When excluding the one study consisting of only patients with persistent AF, the heterogeneity improved substantially (I2=0%, Cochran's Q P=0.55) with a similar estimate of effect (relative risk, 0.78 [95% CI, 0.71-0.85]; P<0.001). CONCLUSIONS Shorter duration between time of first AF diagnosis and AF ablation is associated with an increased likelihood of ablation procedural success. Additional study is required to confirm these results and to explore implementation of earlier catheter AF ablation and patient outcomes within the current AF care pathway. Visual Overview A visual overview is available for this article.
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Affiliation(s)
- Derek S Chew
- Duke Clinical Research Institute, Duke University, Durham, NC (D.S.C., E.B.-M., Z.L., D.B.M., J.P.P.)
| | - Eric Black-Maier
- Duke Clinical Research Institute, Duke University, Durham, NC (D.S.C., E.B.-M., Z.L., D.B.M., J.P.P.)
| | - Zak Loring
- Duke Clinical Research Institute, Duke University, Durham, NC (D.S.C., E.B.-M., Z.L., D.B.M., J.P.P.)
| | - Peter A Noseworthy
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (P.A.N., D.L.P.)
| | - Douglas L Packer
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (P.A.N., D.L.P.)
| | - Derek V Exner
- Libin Cardiovascular Institute of Alberta, University of Calgary, Canada (D.V.E.)
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University, Durham, NC (D.S.C., E.B.-M., Z.L., D.B.M., J.P.P.)
| | - Jonathan P Piccini
- Duke Clinical Research Institute, Duke University, Durham, NC (D.S.C., E.B.-M., Z.L., D.B.M., J.P.P.)
- Duke Center for Atrial Fibrillation, Department of Medicine, Duke University Medical Center, Durham, NC (J.P.P.)
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Al-Khatib SM, Benjamin EJ, Buxton AE, Calkins H, Chung MK, Curtis AB, Desvigne-Nickens P, Jais P, Packer DL, Piccini JP, Rosenberg Y, Russo AM, Wang PJ, Cooper LS, Go AS. Research Needs and Priorities for Catheter Ablation of Atrial Fibrillation: A Report From a National Heart, Lung, and Blood Institute Virtual Workshop. Circulation 2019; 141:482-492. [PMID: 31744331 DOI: 10.1161/circulationaha.119.042706] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Catheter ablation has brought major advances in the management of patients with atrial fibrillation (AF). As evidenced by multiple randomized trials, AF catheter ablation can reduce the risk of recurrent AF and improve quality of life. In some studies, AF ablation significantly reduced cardiovascular hospitalizations. Despite the existing data on AF catheter ablation, numerous knowledge gaps remain concerning this intervention. This report is based on a recent virtual workshop convened by the National Heart, Lung, and Blood Institute to identify key research opportunities in AF ablation. We outline knowledge gaps related to emerging technologies, the relationship between cardiac structure and function and the success of AF ablation in patient subgroups in whom clinical benefit from ablation varies, and potential platforms to advance clinical research in this area. This report also considers the potential value and challenges of a sham ablation randomized trial. Prioritized research opportunities are identified and highlighted to empower relevant stakeholders to collaborate in designing and conducting effective, cost-efficient, and transformative research to optimize the use and outcomes of AF ablation.
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Affiliation(s)
- Sana M Al-Khatib
- Division of Cardiology and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (S.M.A., J.P.P.)
| | - Emelia J Benjamin
- Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, and Department of Epidemiology, Boston University School of Public Health, MA (E.J.B.)
| | - Alfred E Buxton
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (A.E.B.)
| | - Hugh Calkins
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD (H.C.)
| | - Mina K Chung
- Department of Cardiovascular Medicine, Cleveland Clinic, OH (M.K.C.)
| | - Anne B Curtis
- Department of Medicine, University at Buffalo School of Medicine and Biomedical Sciences, NY (A.B.C.)
| | - Patrice Desvigne-Nickens
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.D.N., Y.R., L.S.C.)
| | - Pierre Jais
- Cardiology Hospital, University of Bordeaux, France (P.J.)
| | - Douglas L Packer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (D.L.P.)
| | - Jonathan P Piccini
- Division of Cardiology and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (S.M.A., J.P.P.)
| | - Yves Rosenberg
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.D.N., Y.R., L.S.C.)
| | - Andrea M Russo
- Division of Cardiology, Cooper University, Camden, NJ (A.M.R.)
| | - Paul J Wang
- Departments of Medicine and Health Research and Policy, Stanford University, CA (P.J.W.)
| | - Lawton S Cooper
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.D.N., Y.R., L.S.C.)
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland (A.S.G.).,Departments of Epidemiology, Biostatistics, and Medicine, University of California, San Francisco (A.S.G.)
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50
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Hohmann S, Rettmann ME, Konishi H, Borenstein A, Wang S, Suzuki A, Michalak GJ, Monahan KH, Parker KD, Newman LK, Packer DL. Spatial Accuracy of a Clinically Established Noninvasive Electrocardiographic Imaging System for the Detection of Focal Activation in an Intact Porcine Model. Circ Arrhythm Electrophysiol 2019; 12:e007570. [DOI: 10.1161/circep.119.007570] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Noninvasive electrocardiographic imaging (ECGi) is used clinically to map arrhythmias before ablation. Despite its clinical use, validation data regarding the accuracy of the system for the identification of arrhythmia foci is limited.
Methods:
Nine pigs underwent closed-chest placement of endocardial fiducial markers, computed tomography, and pacing in all cardiac chambers with ECGi acquisition. Pacing location was reconstructed from biplane fluoroscopy and registered to the computed tomography using the fiducials. A blinded investigator predicted the pacing location from the ECGi data, and the distance to the true pacing catheter tip location was calculated.
Results:
A total of 109 endocardial and 9 epicardial locations were paced in 9 pigs. ECGi predicted the correct chamber of origin in 85% of atrial and 92% of ventricular sites. Lateral locations were predicted in the correct chamber more often than septal locations (97% versus 79%,
P
=0.01). Absolute distances in space between the true and predicted pacing locations were 20.7 (13.8–25.6) mm (median and [first–third] quartile). Distances were not significantly different across cardiac chambers.
Conclusions:
The ECGi system is able to correctly identify the chamber of origin for focal activation in the vast majority of cases. Determination of the true site of origin is possible with sufficient accuracy with consideration of these error estimates.
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Affiliation(s)
- Stephan Hohmann
- Translational Interventional Electrophysiology Laboratory (S.H., M.E.R., H.K., S.W., A.S., K.H.M., K.D.P., L.K.N., D.L.P.), Mayo Clinic, Rochester, MN
| | - Maryam E. Rettmann
- Translational Interventional Electrophysiology Laboratory (S.H., M.E.R., H.K., S.W., A.S., K.H.M., K.D.P., L.K.N., D.L.P.), Mayo Clinic, Rochester, MN
| | - Hiroki Konishi
- Translational Interventional Electrophysiology Laboratory (S.H., M.E.R., H.K., S.W., A.S., K.H.M., K.D.P., L.K.N., D.L.P.), Mayo Clinic, Rochester, MN
| | | | - Songyun Wang
- Translational Interventional Electrophysiology Laboratory (S.H., M.E.R., H.K., S.W., A.S., K.H.M., K.D.P., L.K.N., D.L.P.), Mayo Clinic, Rochester, MN
| | - Atsushi Suzuki
- Translational Interventional Electrophysiology Laboratory (S.H., M.E.R., H.K., S.W., A.S., K.H.M., K.D.P., L.K.N., D.L.P.), Mayo Clinic, Rochester, MN
| | | | - Kristi H. Monahan
- Translational Interventional Electrophysiology Laboratory (S.H., M.E.R., H.K., S.W., A.S., K.H.M., K.D.P., L.K.N., D.L.P.), Mayo Clinic, Rochester, MN
| | - Kay D. Parker
- Translational Interventional Electrophysiology Laboratory (S.H., M.E.R., H.K., S.W., A.S., K.H.M., K.D.P., L.K.N., D.L.P.), Mayo Clinic, Rochester, MN
| | - L. Katie Newman
- Translational Interventional Electrophysiology Laboratory (S.H., M.E.R., H.K., S.W., A.S., K.H.M., K.D.P., L.K.N., D.L.P.), Mayo Clinic, Rochester, MN
| | - Douglas L. Packer
- Translational Interventional Electrophysiology Laboratory (S.H., M.E.R., H.K., S.W., A.S., K.H.M., K.D.P., L.K.N., D.L.P.), Mayo Clinic, Rochester, MN
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