Catheter ablation vs electrophysiologically guided thoracoscopic surgical ablation in long-standing persistent atrial fibrillation: The CASA-AF Study

      Background

      Catheter ablation (CA) outcomes for long-standing persistent atrial fibrillation (LSPAF) remain suboptimal. Thoracoscopic surgical ablation (SA) provides an alternative approach in this difficult to treat cohort.

      Objective

      To compare electrophysiological (EP) guided thoracoscopic SA with percutaneous CA as the first-line strategy in the treatment of LSPAF.

      Methods

      Fifty-one patients with de novo symptomatic LSPAF were recruited. Twenty-six patients underwent electrophysiologically guided thoracoscopic SA. Conduction block was tested for all lesions intraoperatively by an independent electrophysiologist. In the CA group, 25 consecutive patients underwent stepwise left atrial (LA) ablation. The primary end point was single-procedure freedom from atrial fibrillation (AF) and atrial tachycardia (AT) lasting >30 seconds without antiarrhythmic drugs at 12 months.

      Results

      Single- and multiprocedure freedom from AF/AT was higher in the SA group than in the CA group: 19 of 26 patients (73%) vs 8 of 25 patients (32%) (P = .003) and 20 of 26 patients (77%) vs 15 of 25 patients (60%) (P = .19), respectively. Testing of the SA lesion set by an electrophysiologist increased the success rate in achieving acute conduction block by 19%. In the SA group, complications were experienced by 7 of 26 patients (27%) vs 2 of 25 patients (8%) in the CA group (P = .07).

      Conclusion

      In LSPAF, meticulous electrophysiologically guided thoracoscopic SA as a first-line strategy may provide excellent single-procedure success rates as compared with those of CA, but there is an increased up-front risk of nonfatal complications.

      Keywords

      Abbreviations:

      AF (atrial fibrillation), AT (atrial tachycardia), CA (catheter ablation), GP (ganglionated plexi), ITT (intention to treat), LA (left atrial), LLPV (left lower pulmonary vein), LSPAF (long-standing persistent atrial fibrillation), LUPV (left upper pulmonary vein), PV (pulmonary vein), PVI (pulmonary vein isolation), SA (surgical ablation), SR (sinus rhythm)
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