In early persistent atrial fibrillation patients with large left atrial volume (>148 cm3), LARIAT plus PVI increased freedom from atrial arrhythmias compared with PVI alone (69% vs 49%; P=0.02).
RCT (n=610)
2:1
Yes
Does left atrial appendage ligation in addition to PVI improve freedom from atrial arrhythmias compared to PVI alone in patients with nonparoxysmal AF and enlarged left atrial volume?
Left atrial appendage ligation in addition to PVI may provide adjunctive benefit in maintaining freedom from atrial arrhythmias in patients with nonparoxysmal AF and enlarged left atrial volume.
Absolute Event Rate: 69% vs 49%
p-value: p=0.02
BACKGROUND: Large left atrial volume (LAV) is a strong predictor of advanced left atrial substrate and is associated with less successful outcomes following pulmonary vein isolation (PVI) alone. Prespecified variables of the aMAZE trial were evaluated to access for the impact of LAV and left atrial appendage ligation on atrial fibrillation (AF) outcomes. METHODS: The aMAZE trial (REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02513797) was a multicenter, randomized-controlled study evaluating the effects of LAV on freedom from atrial arrhythmias (AA) following PVI-only compared with LARIAT and PVI (LARIAT+PVI). In total, 610 drug-refractory patients with nonparoxysmal AF were randomized 2:1 to LARIAT versus PVI alone. Freedom from AA was assessed 12 months postprocedure. LAV was independently assessed by a core laboratory from cardiac computed tomography performed before ablation. RESULTS: There were 404 patients in the LARIAT+PVI group and 206 in the PVI-only group. Logistic regression performed within each subgroup for primary effectiveness with LAV demonstrated that the recurrence of AA after PVI was directly related to increasing LAV. Freedom from recurrence of AA in the LARIAT+PVI arm was independent and preserved irrespective of LAV. Similar results were seen with LAV index. A tercile analysis of early persistent AF (perAF) patients (AF >7 days and 148 cm 3 ) LAV tercile showed statistically significant freedom from AA compared with PVI-only (69% versus 49%; P =0.02). Significant differences ( P <0.04) between groups in the early perAF cohort began at an LAV of 130 cm 3 and an LAV index of 65 cm 3 /m 2 . CONCLUSIONS: The correlation of LAV with PVI effectiveness in this study demonstrates that AA recurrence after PVI alone is directly related to increasing LAV. Freedom from AA after left atrial appendage ligation in addition to PVI is independent of increasing LAV, and left atrial appendage ligation may therefore provide an adjunctive benefit in patients with nonparoxysmal AF and enlarged LAV.
A key sub-analysis of the aMAZE trial demonstrates that adjunctive left atrial appendage ligation improves freedom from atrial arrhythmias after PVI, particularly in patients with enlarged left atria.
Lakkireddy et al. (Tue,) conducted a rct in nonparoxysmal atrial fibrillation (n=610). LARIAT and PVI vs. PVI alone was evaluated on Freedom from atrial arrhythmias (AA) (p=0.02). In early persistent atrial fibrillation patients with large left atrial volume (>148 cm3), LARIAT plus PVI increased freedom from atrial arrhythmias compared with PVI alone (69% vs 49%; P=0.02).
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