Catheter ablation vs. thoracoscopic surgical ablation in long-standing persistent atrial fibrillation: CASA-AF randomized controlled trial

Abstract

Aims Long-standing persistent atrial fibrillation (LSPAF) is challenging to treat with suboptimal catheter ablation (CA) outcomes. Thoracoscopic surgical ablation (SA) has shown promising efficacy in atrial fibrillation (AF). This multicentre randomized controlled trial tested whether SA was superior to CA as the first interventional strategy in de novo LSPAF. Methods and results We randomized 120 LSPAF patients to SA or CA. All patients underwent predetermined lesion sets and implantable loop recorder insertion. Primary outcome was single procedure freedom from AF/atrial tachycardia (AT) ≥30 s without anti-arrhythmic drugs at 12 months. Secondary outcomes included clinical success (≥75% reduction in AF/AT burden); procedure-related serious adverse events; changes in patients’ symptoms and quality-of-life scores; and cost-effectiveness. At 12 months, freedom from AF/AT was recorded in 26% (14/54) of patients in SA vs. 28% (17/60) in the CA group [OR 1.128, 95% CI (0.46–2.83), P = 0.83]. Reduction in AF/AT burden ≥75% was recorded in 67% (36/54) vs. 77% (46/60) [OR 1.13, 95% CI (0.67–4.08), P = 0.3] in SA and CA groups, respectively. Procedure-related serious adverse events within 30 days of intervention were reported in 15% (8/55) of patients in SA vs. 10% (6/60) in CA, P = 0.46. One death was reported after SA. Improvements in AF symptoms were greater following CA. Over 12 months, SA was more expensive and provided fewer quality-adjusted life-years (QALYs) compared with CA (0.78 vs. 0.85, P = 0.02). Conclusion Single procedure thoracoscopic SA is not superior to CA in treating LSPAF. Catheter ablation provided greater improvements in symptoms and accrued significantly more QALYs during follow-up than SA. Clinical Trial Registration ISRCTN18250790 and ClinicalTrials.gov: NCT02755688

Ablation of persistent atrial fibrillation: the added value of hybrid

“…Given the large temporal difference in rhythm assessment between both methods, the use of ILR potentially could lead to much lower success rates than the overall reported success rate of 70% after hybrid approaches using Holter monitoring [ 3 ]. It is reassuring that the current study of Lapenna et al shows otherwise, and the results stand in striking contrast to those of the recent study of Haldar et al [ 8 ]. The CASA-AF trial, randomizing non-paroxysmal AF patients to either thoracoscopic or catheter AF ablation, the follow-up with ILR showed that only 26% of patients were arrhythmia-free 1 year after thoracoscopic AF ablation [ 8 ].…”

“…It is reassuring that the current study of Lapenna et al shows otherwise, and the results stand in striking contrast to those of the recent study of Haldar et al [ 8 ]. The CASA-AF trial, randomizing non-paroxysmal AF patients to either thoracoscopic or catheter AF ablation, the follow-up with ILR showed that only 26% of patients were arrhythmia-free 1 year after thoracoscopic AF ablation [ 8 ]. However, a more extensive ablation strategy in the catheter group and potential limitation in surgical experience (only 20 procedures were minimally required) are important factors that contributed to these disappointing results, besides the fact that it was a none hybrid approach [ 8 ].…”

Total thoracoscopic ablation in patients with atrial fibrillation and left ventricular dysfunction

“… 8 , 11 In a recent randomized trial of catheter ablation versus thoracoscopic surgical ablation in long-standing persistent AF (CASA-AF), thoracoscopic surgical ablation had a 15% rate of serious complications within 30 days, including 1 death. 21 A systemic safety analysis of TTA found a 30-day postoperative complication rate of 11.8%. 9 Surgical ablation is part of a growing trend toward less invasive and thoracoscopic approaches, during which complications related to surgery can be expected to decrease.…”

Cardiology on the cutting edge: updates from the European Society of Cardiology (ESC) Congress 2020

“…Interesting news came from the AF field, not only due to the publication of the updated guidelines [8], but also from the results of three major studies-the EAST-AFNET 4 (Early Treatment of Atrial Fibrillation for Stroke Prevention Trial), RATE-AF (Rate Control Therapy Evaluation in Permanent Atrial Fibrillation), and CASA-AF (Catheter Ablation Versus Thoracoscopic Surgical Ablation in Long Standing Persistent Atrial Fibrillation) [29]. The EAST-AFNET 4 found that the early initiation of a rhythm control therapy was associated with a reduced risk of CV outcomes (death from CV causes, stroke, hospitalization for HF, or ACS) than usual care in those patients with early AF and other CV diseases across a 5-year follow-up period [20].…”

“…Indeed, this study showed that digoxin was associated with symptom improvement and reduction in N-terminal-pro B-type natriuretic peptide compared with a β-blocker in patients with permanent AF [12]. CASA-AF demonstrated that surgical ablation was not superior to catheter ablation in treating long-standing persistent AF, while catheter ablation allowed greater symptomatic relief, cost-effectiveness, and quality of life [29].…”