Recurrence of Atrial Fibrillation After Catheter Ablation in the CABANA Trial
abstract
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Access this abstract now Full Text Available for ClinicalKey SubscribersBACKGROUND
The CABANA (Catheter Ablation Versus Antiarrhythmic Drug Therapy for Atrial Fibrillation) trial randomized 2,204 patients with atrial fibrillation (AF) to catheter ablation or drug therapy. Analysis by intention-to-treat showed a nonsignificant 14% relative reduction in the primary outcome of death, disabling stroke, serious bleeding, or cardiac arrest.
OBJECTIVES
The purpose of this study was to assess recurrence of AF in the CABANA trial.
METHODS
The authors prospectively studied CABANA patients using a proprietary electrocardiogram recording monitor for symptom-activated and 24-h AF auto detection. The AF recurrence endpoint was any post-90-day blanking atrial tachyarrhythmias lasting 30 s or longer. Biannual 96-h Holter monitoring was used to assess AF burden. Patients who used the CABANA monitors and provided 90-day post-blanking recordings qualified for this analysis (n = 1,240; 56% of CABANA population). Treatment comparisons were performed using a modified intention-to-treat approach.
RESULTS
Median age of the 1,240 patients was 68 years, 34.4% were women, and AF was paroxysmal in 43.0%. Over 60 months of follow-up, first recurrence of any symptomatic or asymptomatic AF (hazard ratio: 0.52; 95% confidence interval: 0.45 to 0.60; p < 0.001) or first symptomatic-only AF (hazard ratio: 0.49; 95% confidence interval: 0.39 to 0.61; p < 0.001) were both significantly reduced in the catheter ablation group. Baseline Holter AF burden in both treatment groups was 48%. At 12 months, AF burden in ablation patients averaged 6.3%, and in drug-therapy patients, 14.4%. AF burden was significantly less in catheter ablation compared with drug-therapy patients across the 5-year follow-up (p < 0.001). These findings were not sensitive to the baseline pattern of AF.
CONCLUSIONS
Catheter ablation was effective in reducing recurrence of any AF by 48% and symptomatic AF by 51% compared with drug therapy over 5 years of follow-up. Furthermore, AF burden was also significantly reduced in catheter ablation patients, regardless of their baseline AF type.
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Additional Info
Recurrence of Atrial Fibrillation After Catheter Ablation or Antiarrhythmic Drug Therapy in the CABANA Trial
J Am Coll Cardiol 2020 Jun 30;75(25)3105-3118, JE Poole, TD Bahnson, KH Monahan, G Johnson, H Rostami, AP Silverstein, HR Al-Khalidi, Y Rosenberg, DB Mark, KL Lee, DL Packer,From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
The CABANA trial was designed to compare the efficacy of catheter ablation with drug therapy in 1108 patients with symptomatic atrial fibrillation (AF) randomized to ablation versus 1096 patients randomized to rate- or rhythm-control drug therapy. At 4 years, the primary outcome showed a 14% nonsignificant reduction in a composite of death, disabling stroke, serious bleeding, or cardiac arrest by intention-to-treat analysis and a 15% nonsignificant reduction in the secondary endpoint of all-cause mortality.
A secondary objective of the CABANA trial defined the long-term risk of AF recurrence in terms of first recurrence and burden of AF.1 Over 5 years of follow-up, catheter ablation significantly reduced any AF recurrence by 48% and symptomatic AF by 51% compared with drug therapy. In addition, AF burden was also significantly reduced in catheter ablation patients, regardless of their baseline AF type.
The take-home message for clinicians treating AF patients is that catheter ablation results in a substantial and clinically important reduction of recurrent symptomatic and asymptomatic AF over 5 years of follow-up and should be considered early in the treatment of these patients.
Many AF patients cannot or do not want to maintain anticoagulation with warfarin. Because most emboli during atrial fibrillation (AF) arise in the left atrial appendage, percutaneous closure of the LAA (LAAC) has been tested as a substitute for warfarin anticoagulation. In two randomized trials, LAAC was found to be noninferior to warfarin for all stroke or systemic embolism and was associated with 78% reduction in hemorrhagic stroke and 52% reduction in cardiovascular mortality.
Because direct oral anticoagulants (DOACs) demonstrate improved safety compared with warfarin, and their effect on cardiovascular and neurological outcomes relative to LAAC is unknown, the present randomized, multicenter, noninferiority trial compared DOACs (201 patients) with LAAC (201 patients) in AF patients at increased risk for stroke and bleeding.2 The authors found that LAAC was noninferior to DOACs in preventing major AF-related cardiovascular, neurological, and bleeding events.
The take-home message for clinicians is to consider LAAC in nonvalvular AF patients at high risk for stroke and increased risk of bleeding because mechanical LAAC is noninferior to DOACs for the composite of cardioembolic events, cardiovascular death, clinically significant bleeding, or procedure-/device-related complications. However, the authors caution that safety issues remain with LAAC that warrant further refinements in both operator technique and device technology.
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