Background
First-line ablation for atrial fibrillation (AF) reduces the risk of recurrent atrial arrhythmias compared to medical therapy. However, the prognostic benefit of early AF ablation remains undetermined. Herein, we aimed to evaluate the effects of early AF ablation compared to medical therapy.
Methods
Using data from phase II/III of the GLORIA-AF registry, we studied patients who were consecutively enrolled with newly diagnosed AF (< 3 months before baseline visit) and an increased risk of stroke (CHA2DS2–VASc ≥ 1). At baseline visit, 445 (1.7%) patients were treated with early AF ablation and 25,518 (98.3%) with medical therapy. Outcomes of interest were the composite outcome of all-cause death, stroke and major bleeding, and pre-specified outcomes of all-cause death, cardiovascular (CV) death, non-CV death, stroke and major bleeding.
Results
A total of 25,963 patients (11733 [45.2%] females; median age 71 [IQR 64–78] years; 17424 [67.1%] taking non-vitamin K antagonist oral anticoagulants [NOACs]) were included. Over a follow-up period of 3.0 (IQR 2.3–3.1) years, after adjustment for confounders, early AF ablation was associated with a significant reduction in the composite outcome of all-cause death, stroke and major bleeding (HR 0.50 [95% CI 0.30–0.85]) and all-cause death (HR 0.45 [95% CI 0.23–0.91]). There were no statistical differences between the groups in terms of CV death, non-CV death, stroke and major bleeding. Similar results were obtained in a propensity-score matched analysis of patients with comparable baseline variables.
Conclusions
Early AF ablation in a contemporary prospective cohort of AF patients who were predominantly treated with NOACs was associated with a survival advantage compared to medical therapy alone.
Trial registration
Clinical trial registration: http://www.clinicaltrials.gov. Unique identifiers: NCT01468701, NCT01671007 and NCT01937377.
Graphical abstract
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Introduction
Radiofrequency catheter ablation is a cornerstone of treatment for many cardiac arrhythmias. Progression in three‐dimensional mapping and contact‐force sensing technologies have improved our capability to achieve success, but challenges still remain.
Methods
In this article, we discuss the importance of overall circuit impedance in radiofrequency lesion formation. This is followed by a review of the literature regarding recently developed “local impedance” technology and its current and future potential applications and limitations, in the context of established surrogate markers currently used to infer effective ablation.
Results
We discuss the role of local impedance in assessing myocardial substrate, as well as its role in clinical studies of ablation. We also discuss safety considerations, limitations and ongoing research.
Conclusion
Local impedance is a novel tool which has the potential to tailor ablation in a manner distinct from other established metrics.
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