Lisbon, Portugal - 17 March 2019: A day case catheter ablation procedure which includes only the bare essentials and delivers the same outcomes could slash waiting lists for atrial fibrillation patients, according to late-breaking results from the AVATAR-AF trial presented today at EHRA 2019, a European Society of Cardiology (ESC) congress.1 With the simplified protocol, 30% more patients could receive catheter ablation for the same cost.
Atrial fibrillation is the most common heart rhythm disorder (arrhythmia). It causes 20-30% of all strokes and increases the risk of dying prematurely.2 Symptoms include palpitations, shortness of breath, tiredness, and difficulty exercising. Catheter ablation, aimed at burning or freezing heart tissue causing atrial fibrillation, is recommended to restore normal rhythm after failure of, or intolerance to, drug treatment.
Principal investigator Professor Prapa Kanagaratnam, of Imperial College London, UK, said: "Catheter ablation started in 1998. There has been little improvement in clinical outcomes in the last ten years despite costlier technologies and a more complicated procedure requiring highly skilled staff. In this trial, we stripped the procedure back to the bare essentials to see if it achieved the same outcomes."
The AVATAR protocol eliminates electrical mapping of the pulmonary veins, thereby removing the need for pulmonary vein catheters, electrical recording equipment, and staff trained to use the equipment.
The trial enrolled 321 patients with atrial fibrillation needing symptom control. Patients were randomly allocated to one of three treatments: 1) AVATAR protocol with cryoballoon ablation and discharge home the same day; 2) antiarrhythmic drugs; 3) conventional cryoballoon ablation with pulmonary vein mapping, and overnight hospitalisation.
For all patients, there was a 12 week treatment period during which procedures were done and drugs were optimised. The primary endpoint was whether patients needed to attend hospital again after that period.
At one year, 21% of patients in the AVATAR group needed hospital treatment to relieve symptoms. This was significantly lower than in the drug therapy group, of whom 76% needed therapy (p<0.0001), and not significantly different to the conventional ablation group, of whom 18% required treatment (p=0.6).
"Some of the more technical parts of the procedure can be omitted, making it easier, cheaper and quicker, without sacrificing results." said Professor Kanagaratnam. "In the UK, patients with atrial fibrillation have to wait months for catheter ablation. The simpler protocol could shorten waiting lists within the same budget."
"Eight in ten patients didn't need to see their specialist again," he continued. "Currently we medicalise patients with regular monitoring, but the study shows that long-term follow-up is unnecessary. Patients can contact the hospital if they have symptoms."
The study gives the first direct proof that ablation is better than drugs for controlling symptoms and avoiding hospital treatment. "It is possible that more patients will now choose catheter ablation outright, rather than trying drugs first," said Professor Kanagaratnam. "The findings also question the value of drug therapy, and whether catheter ablation should be the first line treatment for atrial fibrillation patients with symptoms."
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Authors: ESC Press Office
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Notes to editor
The hashtag for the meeting is #ehra2019.
Sources of funding: British Heart Foundation, Medtronic, National Institute for Health Research.
Disclosures: None.
References and notes
1The abstract 'Ablation versus antiarrhythmic therapy for reducing all hospital episodes from recurrent atrial fibrillation' will be presented during the session Late-breaking trials 1 on Sunday 17 March at 14:00 to 15:30 WET (GMT) in the Sokolov lecture room.
2Kirchhof P, Benussi S, Kotecha D, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016;37:2893-2962.
About the European Heart Rhythm Association
The European Heart Rhythm Association (EHRA) is a branch of the European Society of Cardiology (ESC). Its aim is improving the quality of life and reducing sudden cardiac death by limiting the impact of heart rhythm disturbances. EHRA ensures the dissemination of knowledge and standard setting; provides continuous education, training and certification to physicians and allied professionals involved in the field of cardiac arrhythmias with a special focus on Atrial Fibrillation (AF) and Electrophysiology (EP). EHRA releases international consensus documents and position papers, it is a source of high quality, unbiased, evidence based, scientific information that promotes the quality of care for patients with AF, and for, has also dedicated a website for patients "afibmatters.org".
About the EHRA Congress
EHRA 2019 is the annual congress of the European Heart Rhythm Association (EHRA) of the European Society of Cardiology (ESC).
About the European Society of Cardiology
The European Society of Cardiology brings together health care professionals from more than 150 countries, working to advance cardiovascular medicine and help people lead longer, healthier lives.
Information for journalists attending EHRA 2019
EHRA 2019 will be held 17 to 19 March at the Lisbon Congress Centre (CCL) in Lisbon, Portugal. Explore the scientific programme.
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