Double wide-area circumferential ablation not associated with improved freedom from recurrent atrial arrhythmias

1. In this randomized clinical trial that included 398 patients with paroxysmal atrial fibrillation (AF), performing a double wide-area circumferential ablation (WACA) did not improve freedom from recurrent atrial arrhythmias compared with a standard single ablation set.

2. Overall, 26.7% of patients in the single WACA arm and 24.6% in the double WACA arm had recurrent atrial arrhythmias at one year.

Evidence Rating Level:1 (Excellent)

Study Rundown: Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia, affecting millions of individuals globally. Catheter ablation techniques such as pulmonary vein isolation (PVI) have been proven effective in managing patients with paroxysmal AF. However, catheter ablation is expensive and limited by AF recurrence in up to 47% of patients, leading to poorer quality of life and the need for additional ablation procedures. This study aimed to evaluate the superiority of an augmented double wide-area circumferential ablation (WACA) compared with a single WACA in preventing the recurrence of atrial arrhythmias such as AF. A total of 398 patients were included in this multicenter, prospective, randomized clinical trial and were randomized (1:1) to receive radiofrequency catheter ablation for PVI with either a standard single WACA or a double WACA. The primary outcome was atrial arrhythmia recurrence up to 1-year post-ablation. Results from this study demonstrated that at one year, 52 patients (26.7%) in the single WACA arm and 50 patients (24.6%) in the double WACA group had recurrent episodes of atrial arrhythmia, a difference that was not significant. A strength of this study was its novel approach to evaluating two strategies for radiofrequency catheter ablation. A limitation, however, was that the trial did not have a sufficient sample size to test the hypothesis that estimated a 33% recurrence rate for atrial arrhythmias.

Click to read the study in JAMA Cardiology

Relevant Reading: Rhythm-monitoring strategy and arrhythmia recurrence in atrial fibrillation ablation trials: a systematic review

In-Depth [randomized controlled trial]: This study investigated augmented double WACA compared with standard single WACA in preventing recurrent atrial arrhythmias. Patients with symptomatic paroxysmal AF were recruited between March 2015 and May 2017. A total of 398 patients with paroxysmal AF were randomized (1:1) to receive radiofrequency catheter ablation for PVI with either a standard single WACA or an augmented double WACA. 195 were randomized to the single WACA control arm (mean [SD] age, 60.6 [9.3] years; 65 [33.3%] female) and 203 to the double WACA experimental arm (mean [SD] age, 61.5 [9.3] years; 66 [32.5%] female. A total of 52 patients (26.7%) in the control arm and 50 patients (24.6%) in the experimental group had recurrent atrial arrhythmias at one year (relative risk, 0.92; 95% CI, 0.66-1.29; P = .64. 20 patients (10.3%) in the single WACA arm and 15 patients (7.4%) in the double WACA received repeated catheter ablation (relative risk, 0.72; 95% CI, 0.38 – 1.36). Adjudicated serious adverse events were found to have occurred in 14 patients (6.9%) in the experimental arm and 13 patients (6.7%) in the control arm.

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