Rationale: Atrial fibrillation (AF) is a highly prevalent cardiac arrhythmia. AF is classified as paroxysmal or persistent AF, based on the duration and persistency of the arrhythmia. Despite state-of-the-art pharmacological therapies targeting the ventricular rate or aiming to restore sinus rhythm, many patients with persistent AF stay symptomatic. Catheter ablation, endocardial pulmonary vein isolation (PVI) in particular, is the most commonly applied approach to treat drug refractory persistent AF, but particularly in this patient group results are modest. Alternatively, the PVs can be approached epicardially by thoracoscopic surgery to isolate the PVs. This approach is more efficacious, at the cost of a more invasive procedure and longer hospital stay. However, no studies have been conducted comparing catheter with thoracoscopic ablation in patients with persistent AF as a primary invasive procedure after failing treatment with anti-arrhythmic medication.
Objective: This current study aims to assess a patient specific therapy plan for patients with persistent AF by randomizing thoracoscopic versus catheter ablation for PVI without adjuvant substrate ablation in those patients.
Study design: This is a prospective, non-blinded randomized multicenter study. Subjects will be randomized (1:1) to one of the two study-arms (thoracoscopic surgical or catheter PVI). The follow-up will last 5 years, with heart rhythm monitoring at three and six months, one year and yearly in the following years. In case AF recurs during the first year, the subject will receive the treatment of the otherother arm, or according to patient choice or clinical routine.
Study population: Patients with an indication for invasive treatment of persistent AF.
Intervention: Thoracoscopic surgical or catheter PVI without additional lesions.
Age is between 18 and 80 years
Persistent AF as defined following the ESC 2016 Guidelines, evidenced by 1) ongoing AF on the ECG or 2) documentation of AF necessitating cardioversion.
AF documented by ECG or Holter < 1 year ago.
At least one class I or III anti-arrhythmic drug in standard dosage has failed or is not tolerated.
Prior intervention (catheter ablation or minimally-invasive thoracoscopic ablation) for AF.
AF is secondary to electrolyte imbalance, thyroid disease or other reversible or non-cardiovascular causes.
Documentation of CTI dependent atrial flutter
Valvular AF
Parallel
Thoracoscopic pulmonary vein isolation without additional lesion + left atrial appendage exclusion/amputation
Procedure/SurgeryBilateral pulmonary vein isolation using radiofrequency energy
Catheter pulmonary vein isolation without additional lesions
Procedure/SurgeryBilateral pulmonary vein isolation using radiofrequency energy
Freedom of AF, defined as absence of any atrial tachyarrhythmia
The primary endpoint of the study is freedom of AF, defined as absence of any atrial tachyarrhythmia without the use of antiarrhythmic drugs once a total number of 72 patients with AF recurrences after a single procedure have been reached. This is an event based endpoint. Freedom of atrial tachyarrhythmia is defined as the absence of documentation of episodes of atrial tachyarrhythmia lasting more than 30 seconds on Holter recordings during follow-up and/or on ECGs recorded outside the scope of the study.
One year freedom of AF
Freedom of arrhythmia with or without AAD after a single procedure after one year
Freedom of AF after two procedures
Freedom of arrhythmia after 12 months with or without AAD after both procedures
Long term freedom of AF
Freedom of arrhythmia after 5 years
Cost-effectiveness
calculation of cost-effectiveness of both procedures in isolation, and the combination of both procedures.
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