The latest findings from the AVATAR-AF trial presented at EHRA 2019, a European Society of Cardiology (ESC) congress, suggest that a catheter ablation procedure that includes only the bare essentials and delivers the same outcomes can slash waiting lists for atrial fibrillation patients. Researchers claim the simplified protocol could enable 30% more patients to receive catheter ablation for the same cost.
Atrial fibrillation (AF), the most common cardiac arrhythmia, causes 20-30% of all strokes and increases the risk of dying prematurely. Symptoms include palpitations, shortness of breath, tiredness, and difficulty exercising. Catheter ablation, aimed at burning or freezing heart tissue causing AF, is recommended to restore normal rhythm after failure of, or intolerance to, drug treatment.
The "Ablation Versus Antiarrhythmic Therapy for Reducing All Hospital Episodes from Recurrent Atrial Fibrillation" (AVATAR-AF) trial gives the first direct proof that ablation is better than drugs for controlling symptoms and avoiding hospital treatment, according to the researchers led by Professor Prapa Kanagaratnam, of Imperial College London, UK.
In this trial, Prof. Kanagaratnam and co-researchers stripped the catheter ablation procedure “back to the basics” to see if it achieved the same outcomes. The AVATAR protocol eliminates electrical mapping of the pulmonary veins, thereby removing the need for pulmonary vein catheters, electrical recording equipment, and staff trained to use the equipment.
The trial included 321 patients with AF needing symptom control. Patients were randomly allocated to one of three treatments: 1) AVATAR protocol with cryoballoon ablation and discharge home the same day; 2) antiarrhythmic drugs; 3) conventional cryoballoon ablation with pulmonary vein mapping, and overnight hospitalisation.
All patients underwent a 12-week treatment period during which procedures were done and drugs were optimised. The primary endpoint was whether patients needed to attend hospital again after that period.
At one year, 21% of patients in the AVATAR group needed hospital treatment to relieve symptoms. The number, according to the researchers, was significantly lower than in the drug therapy group, of whom 76% needed therapy (p<0.0001), and not significantly different to the conventional ablation group, of whom 18% required treatment (p=0.6).
"Some of the more technical parts of the procedure can be omitted, making it easier, cheaper and quicker, without sacrificing results," explained Professor Kanagaratnam, who noted that in the UK, patients with AF have to wait months for catheter ablation. The simpler protocol could shorten waiting lists within the same budget, the professor asserted.
In addition, the study also showed that long-term follow-up is unnecessary. "Patients can contact the hospital if they have symptoms," Prof. Kanagaratnam said.
"The findings also question the value of drug therapy, and whether catheter ablation should be the first line treatment for atrial fibrillation patients with symptoms," he continued.
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