Left Atrial Appendage Isolation in Patients With Longstanding Persistent AF Undergoing Catheter Ablation
Luigi Di BiaseJ. David BurkhardtPrasant MohantySanghamitra MohantyJavier SánchezChintan TrivediMahmut F GünesYalçın GökoğlanCarola GianniRodney HortonSakis ThemistoclakisG. Joseph GallinghouseShane BaileyJason ZagrodzkyRichard HongoSalwa BeheiryPasquale SantangeliMichela CasellaAntonio Dello RussoAmin Al‐AhmadPatrick HranitzkyClaudio TondoAndrea Natale
Key result
LAA isolation plus extensive ablation improves 12-month freedom from atrial arrhythmias by ~92% vs ablation alone.
- HR 1.92
- 95% CI 1.3-2.9
- P=0.001
- n=173
Why the study?
Longstanding persistent AF is challenging to treat, and it was unknown whether empirical electrical isolation of the LAA could improve catheter ablation success.
Does empirical electrical left atrial appendage isolation along with extensive ablation reduce the recurrence of atrial arrhythmias in patients with longstanding persistent atrial fibrillation?
Key Points
- To evaluate whether empirical electrical isolation of the left atrial appendage improves long-term rhythm control in patients undergoing catheter ablation for longstanding persistent atrial fibrillation.
- Open-label randomized controlled trial (BELIEF trial; NCT01362738) enrolling patients with longstanding persistent atrial fibrillation.
- Participants were randomly assigned to undergo empirical electrical left atrial appendage isolation plus extensive ablation (Group 1, n=85) or extensive ablation alone (Group 2, n=88).
- The primary endpoint was freedom from atrial arrhythmia recurrence at 12-month follow-up after a single procedure, with cumulative recurrence assessed at 24 months.
- At 12 months after a single procedure, 56% (48/85) of patients in Group 1 were recurrence-free compared with 28% (25/88) in Group 2 (unadjusted HR for recurrence with standard ablation: 1.92, 95% CI: 1.3 to 2.9, log-rank p=0.001; adjusted HR: 2.22, 95% CI: 1.29 to 3.81, p=0.004).
- At 24 months after an average of 1.3 procedures, cumulative success was achieved in 76% (65/85) of Group 1 versus 56% (49/88) of Group 2 (unadjusted HR: 2.24, 95% CI: 1.3 to 3.8, log-rank p=0.003).
Study Design
Type
RCT (n=173)
Blinding
Open-label
Randomization
Randomly assigned
Structured PICO
Does empirical electrical left atrial appendage isolation along with extensive ablation reduce the recurrence of atrial arrhythmias in patients with longstanding persistent atrial fibrillation?
P
Population
173 patients with longstanding persistent atrial fibrillation undergoing catheter ablation, randomized to empirical LAA isolation plus extensive ablation or extensive ablation alone.
I
Intervention
Empirical electrical left atrial appendage (LAA) isolation along with extensive ablation
C
Comparator
Extensive ablation alone
O
Outcome
Recurrence of atrial arrhythmias
Main Result
Hazard Ratio: 1.92 (95% CI 1.3–2.9)
Absolute Event Rate: 56% vs 28%
p-value: p=0.001
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“This study thus points to the importance of LAA as both a trigger as well as substrate for the maintenance of AF in this challenging group of patients. LAA can also serve as a source of focal atrial tachycardias. Thus, in LSPAF patients, LAA isolation, if properly done, can improve outcomes, and should be considered in these patients. The challenge, however, is that the procedure remains technically challenging, even in the hands of experienced operators. Recurrences are common (37% in this study) and there may be a steep learning curve for new operators. Also of concern is the impact of electrical LAA isolation on the mechanical function of LAA and future thrombogenic risk and duration of anticoagulation.”
“The BELIEF trial, 1 of the few positive trial in this LSPAF population, demonstrated that in patients with LSPAF, left atrial appendage electrical isolation, combined with an extensive LA ablation, improved long-term freedom from atrial arrhythmias compared with a more conservative strategy, achieving up to 76% arrhythmia-free survival at a 12-month follow-up after a mean of 1.3 procedures. Despite these findings, none of these approaches has received universal endorsement in current guidelines, and everything beyond PVI does not have class I indication.”
Implication
Empirical electrical isolation of the left atrial appendage in addition to extensive ablation significantly improves freedom from atrial arrhythmias in patients with longstanding persistent AF.
Abstract
BACKGROUND: Longstanding persistent (LSP) atrial fibrillation (AF) is the most challenging type of AF. In addition to pulmonary vein isolation, substrate modification and triggers ablation have been reported to improve freedom from AF in patients with LSPAF. OBJECTIVES: This study sought to assess whether the empirical electrical isolation of the left atrial appendage (LAA) could improve success at follow-up. METHODS: This was an open-label, randomized study assessing the effectiveness of empirical electrical left atrial appendage isolation for the treatment of LSPAF. Patients were randomly assigned to undergo empirical electrical left atrial appendage isolation along with extensive ablation (group 1; n = 85) or extensive ablation alone (group 2; n = 88). Recurrence of atrial arrhythmias was the primary endpoint. Secondary endpoints included cardiac-related hospitalization, all-cause mortality, and stroke at follow-up. RESULTS: Major clinical characteristics were not different between the 2 groups. At 12-month follow-up, 48 (56%) patients in group 1 and 25 (28%) in group 2 were recurrence free after a single procedure (unadjusted hazard ratio [HR] for recurrence with standard ablation: 1.92; 95% confidence interval [CI]: 1.3 to 2.9; log-rank p = 0.001). After adjusting for age, sex, and left atrial size, standard ablation was predictive of recurrence (HR: 2.22; 95% CI: 1.29 to 3.81; p = 0.004). During repeat procedures, empirical electrical left atrial appendage isolation was performed in all patients. After an average of 1.3 procedures, cumulative success at 24-month follow-up was reported in 65 (76%) in group 1 and in 49 (56%) in group 2 (unadjusted HR: 2.24; 95% CI: 1.3 to 3.8; log-rank p = 0.003). CONCLUSIONS: This randomized study showed that both after a single procedure and after redo procedures in patients with LSPAF, empirical electrical isolation of the LAA improved long-term freedom from atrial arrhythmias without increasing complications. (Effect of Empirical Left Atrial Appendage Isolation on Long-term Procedure Outcome in Patients With Persistent or Longstanding Persistent Atrial Fibrillation Undergoing Catheter Ablation [BELIEF]; NCT01362738).
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Cite This Study
Biase et al. (2016) conducted an RCT in Longstanding persistent atrial fibrillation (n=173). Empirical electrical left atrial appendage isolation along with extensive ablation vs. Extensive ablation alone was evaluated on Recurrence of atrial arrhythmias (HR 1.92, 95% CI 1.3-2.9, p=0.001). Empirical electrical left atrial appendage isolation plus extensive ablation improved 12-month freedom from atrial arrhythmias compared to extensive ablation alone (56% vs 28%; P=0.001).