Percutaneous versus thoracoscopic ablation of symptomatic paroxysmal atrial fibrillation: a randomised controlled trial - the FAST II study

Abstract

BackgroundThe most efficient first-time invasive treatment, for achieving sinus rhythm, in symptomatic paroxysmal atrial fibrillation has not been established. We aimed to compare percutaneous catheter and video-assisted thoracoscopic pulmonary vein radiofrequency ablation in patients referred for first-time invasive treatment due to symptomatic paroxysmal atrial fibrillation. The primary outcome of interest was the prevalence of atrial fibrillation with and without anti-arrhythmic drugs at 12 months.MethodsNinety patients were planned to be randomised to either video-assisted thoracoscopic radiofrequency pulmonary vein ablation with concomitant left atrial appendage excision or percutaneous catheter pulmonary vein ablation. Episodes of atrial fibrillation were defined as more than 30 s of atrial fibrillation observed on Holter monitoring/telemetry or clinical episodes documented by ECG.ResultsThe study was terminated prematurely due to a lack of eligible patients. Only 21 patients were randomised and treated according to the study protocol. Thoracoscopic pulmonary vein ablation was performed in 10 patients, and 11 patients were treated with catheter ablation. The absence of atrial fibrillation without the use of anti-arrhythmic drugs throughout the follow-up was observed in 70% of patients following thoracoscopic pulmonary vein ablation and 18% after catheter ablation (p < 0.03).ConclusionThoracoscopic pulmonary vein ablation may be superior to catheter ablation for first-time invasive treatment of symptomatic paroxysmal atrial fibrillation with regard to obtaining sinus rhythm off anti-arrhythmic drugs 12 months postoperative.Trial registrationClinicalTrials.gov Identifier: NCT01336075. Registered April 15th, 2011.

Catheter vs thoracoscopic ablation for atrial fibrillation: Meta‐analysis of randomized trials

“…Second, TA also had higher rates of adverse events particularly thoracic complications. The key clinical characteristics of eligible randomized trials include middle‐aged patients with a high prevalence of paroxysmal AF in 85%, AF duration of 5.9 years, high antiarrhythmic use in 95%, prior failed CA in approximately half, and normal mean left ventricular ejection fraction, but mildly dilated left atrial dimensions on echocardiography 7–12 . Therefore, patients with paroxysmal AF refractory to antiarrhythmic drugs and previous failed CA, but with preserved left ventricular function, are those that our findings best apply to.…”

“…Furthermore, the lower rate of repeat ablation during follow‐up (25% vs 2%) is another distinct advantage of TA. However, the high adverse event rates in up to 25% of TA even in randomized trials is important, observed across four of five studies reporting this 7,8,10,11 . In particularly, thoracic complications much higher in TA are detrimental because of their frequent need of invasive procedures, prolonging of intensive care and/or hospital stay, and potential for long‐term sequelae.…”

“…The greater efficacy seen in five of six trials for TA 7–9,11,12 may be explained by TA being more extensive with additional left atrial lines, targeting of epicardial ganglionic plexi and left atrial appendage ligation 3 . Only one study showed no difference in efficacy, in patients without previous CA, 10 suggesting TA should probably not be attempted as a first‐line therapy before CA.…”

Surgical versus catheter ablation in atrial fibrillation: A systematic review and meta‐analysis of randomized controlled trials

“…Three studies included both refractory paroxysmal and PeAF 6–8 . Two studies included only refractory paroxysmal AF 9,10 . One study included only PeAF 11 .…”

Thoracoscopic epicardial ablation of atrial fibrillation: Safety, efficacy, single center experience

“…9 ). Some data suggest SA may be superior to CA for first-line treatment in PAF, however, at the cost of a higher rate of complications and longer hospitalization 4,6,8,10,11 . In contrast, in the review of Yi et al SA did not show better efficacy results as the first invasive procedure in the subgroup of patients with paroxysmal AF or early persistent AF (ref.…”