Key result
Extensive ablation plus PVI cuts arrhythmia recurrence ~55% vs. PVI alone in persistent AF.
Why the study?
It was hypothesized that the DR-FLASH score could identify patients with persistent AF who require PVI-plus versus those for whom PVI-only is sufficient.
Does extensive ablation in addition to pulmonary vein isolation reduce atrial arrhythmia recurrence compared to pulmonary vein isolation alone in patients with persistent atrial fibrillation stratified by DR-FLASH score?
RCT (n=496)
Open-label
Randomized to receive either PVI-alone or extensive ablation
Yes
Does extensive ablation in addition to pulmonary vein isolation reduce atrial arrhythmia recurrence compared to pulmonary vein isolation alone in patients with persistent atrial fibrillation stratified by DR-FLASH score?
The DR-FLASH score is a useful noninvasive tool to identify patients with persistent atrial fibrillation who benefit from extensive substrate ablation in addition to pulmonary vein isolation.
Answers are grounded in this paper and cite their sources.
DR-FLASH >3 may identify persistent AF patients for extensive ablation; leaves open randomized confirmation before practice change.
Background Modification of arrhythmogenic substrates with extensive ablation comprising linear and/or complex fractional atrial electrogram ablation in addition to pulmonary vein isolation (PVI‐plus) can theoretically reduce the recurrence of atrial fibrillation. The DR‐FLASH score (score based on diabetes mellitus, renal dysfunction, persistent form of atrial fibrillation, left atrialdiameter >45 mm, age >65 years, female sex, and hypertension) is reportedly useful for identifying patients with arrhythmogenic substrates. We hypothesized that, in patients with persistent atrial fibrillation, the DR‐FLASH score can be used to classify patients into those who require PVI‐plus and those for whom a PVI‐only strategy is sufficient. Methods and Results This study is a post hoc subanalysis of the a multicenter, randomized controlled, noninferiority trial investigating efficacy and safety of pulmonary vein isolation alone for recurrence prevention compared with extensive ablation in patients with persistent atrial fibrillation (EARNEST‐PVI trial). This analysis focuses on the relationship between DR‐FLASH score and the efficacy of different ablation strategies. We divided the population into 2 groups based on a DR‐FLASH score of 3 points. A total of 469 patients were analyzed. Among those with a DR‐FLASH score >3 (N=279), the event rate of atrial arrhythmia recurrence was significantly lower in the PVI‐plus arm than in the PVI‐only arm (hazard ratio [HR], 0.45 [95% CI, 0.28–0.72]; P <0.001). In contrast, among patients with a DR‐FLASH score ≤3 (N=217), no differences were observed in the event rate of atrial arrhythmia recurrence between the PVI‐only arm and the PVI‐plus arm (HR, 1.08 [95% CI, 0.61–1.89]; P =0.795). There was significant interaction between patients with a DR‐FLASH score >3 and DR‐FLASH score ≤3 ( P value for interaction=0.020). Conclusions The DR‐FLASH score is a useful tool for deciding the catheter ablation strategy for patients with persistent atrial fibrillation. Registration URL: https://clinicaltrials.gov ; Unique identifier: NCT03514693.
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Sato et al. (2022) conducted an RCT in Persistent atrial fibrillation (n=496). Extensive ablation in addition to pulmonary vein isolation (PVI-plus) vs. Pulmonary vein isolation alone (PVI-alone) was evaluated on Recurrence of atrial fibrillation within 1 year (HR 0.45, 95% CI 0.28-0.72, p=<0.001). In patients with persistent atrial fibrillation and a DR-FLASH score >3, extensive ablation plus pulmonary vein isolation reduced atrial arrhythmia recurrence compared to isolation alone (HR 0.45).
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