Author + information
- Received August 13, 2018
- Revision received October 15, 2018
- Accepted October 16, 2018
- Published online March 18, 2019.
- Wouter R. Berger, MDa,b,∗,
- Jolien Neefs, MDa,∗,
- Nicoline W.E. van den Berg, MDa,
- Sébastien P.J. Krul, MD, PhDa,
- Elise M. van Praag, BSca,
- Femke R. Piersma, RNa,
- Jonas S.S.G. de Jong, MD, PhDb,
- Wim-Jan P. van Boven, MD, PhDc,
- Antoine H.G. Driessen, MD, PhDc and
- Joris R. de Groot, MD, PhDa,∗ ()
- aDepartment of Cardiology, Heart Center, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
- bDepartment of Cardiology, Heart Center, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
- cDepartment of Cardiothoracic Surgery, Heart Center, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
- ↵∗Address for correspondence:
Dr. Joris R. de Groot, Department of Cardiology, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands.
Objectives The authors report the 2-year follow-up results of the AFACT (Atrial Fibrillation Ablation and Autonomic Modulation via Thoracoscopic Surgery) study.
Background The AFACT study randomized patients with advanced atrial fibrillation (AF) to thoracoscopic AF ablation with or without additional ganglion plexus (GP) ablation. At 1 year, there was no difference in AF freedom between the groups, but autonomic modification may exert beneficial effects during longer follow-up.
Methods Patients underwent thoracoscopic pulmonary vein isolation, with additional left atrial lines in persistent AF patients, and were randomized 1:1 to ablation of the 4 major GP and Marshall ligament or no GP ablation (control). Patients were followed every 3 months up to 18 months and at 24 months. After an initial 3-month blanking period, all antiarrhythmic drugs were discontinued.
Results The authors randomized 240 patients (age 59 ± 8 years, 73% men, 68% enlarged left atrium, 60% persistent AF), of whom 228 patients (95%) completed follow-up. Freedom of any atrial tachyarrhythmia did not differ significantly between the GP group (55.6%) and control group (56.1%) (p = 0.91), with no difference in paroxysmal (p = 0.60) or persistent AF patients (p = 0.88). Documented AF recurrences were similar between treatment arms: 11.8% (GP) versus 11.0% (control) had >3 recurrences/year (p = 0.82). More persistent AF patients (17.0%) than paroxysmal (3.2%) had >3 recurrences per year (p < 0.01). Despite this, 78% of patients were off antiarrhythmic drugs after 2 years. No procedural-related complications occurred in the second year.
Conclusions Additional GP ablation during thoracoscopic surgery for advanced AF does not affect freedom of AF recurrence. As GP ablation is associated with more major procedural complications, it should not routinely be performed. (Atrial Fibrillation Ablation and Autonomic Modulation via Thorascopic Surgery [AFACT]; NCT01091389)
Invasive treatment strategies with either catheter or (minimally invasive) surgical ablation are indicated in patients with symptomatic atrial fibrillation (AF), who have failed at least 1 trial of antiarrhythmic drug Class I or III (1). Pulmonary vein isolation (PVI) is the cornerstone in the invasive treatment of AF, but it may be insufficient for persistent or advanced AF (paroxysmal or persistent AF, with enlarged left atria or previously failed catheter ablation) (2). However, the benefit of additional lesion sets remains a matter of debate, especially after the STAR-AF II (Substrate and Trigger Ablation for Reduction of Atrial Fibrillation Trial) showed that additional ablation lines do not affect success rates after ablation (3). Therefore, additional research is needed to elucidate the optimal AF ablation strategy, because an effective strategy reduces AF-related hospitalization, stroke, and mortality rates and increases quality of life (4,5).
The autonomic nervous system has been shown to play a central role in the initiation and perpetuation of AF. More specifically, stimulation of the ganglion plexus (GP) induces rapid ectopic activity from the PV, a process that critically depends on vagally induced action potential shortening and sympathetically driven sarcoplasmic reticulum calcium release (6). Also, stimulation of the GP results in myocardial conduction slowing in addition to sinus arrest and atrioventricular block (7). Clinical evidence suggests that ablation of the GP adds to AF freedom and is more efficacious when based on anatomical landmarks than when based on high-frequency stimulation (HFS) of the atrial neurons (8,9). It has been demonstrated that in patients with paroxysmal AF, endocardial ablation of the GP when added to PVI resulted in higher rates of AF absence during follow-up (10). However, from that study, it seemed that the differential effect of additional GP ablation increased with longer follow-up. Also, whereas most evidence of GP ablation has been obtained in patients with paroxysmal AF, the role of GP ablation in modifying the arrhythmogenic substrate in patients with advanced AF is less clear, and autonomic modulation may actually be proarrhythmogenic in more diseased substrates (11,12).
The AFACT (Atrial Fibrillation Ablation and Autonomic Modulation via Thoracoscopic Surgery) study was designed to investigate the role of ablation of the autonomic GP in addition to thoracoscopic ablation of advanced AF (13). The main results of the study were that additional GP ablation does not increase AF freedom at 1 year of follow-up. On the contrary, GP ablation was associated with significantly more sinus node dysfunction, pacemaker implantations, and periprocedural bleeding. Despite this, it is unknown whether GP ablation exerts intermediate effects that may relate to the reinnervation of the atrium or the absence thereof (14,15). Therefore, we report the 2-year clinical outcome of efficacy and safety measures of additional GP ablation in the AFACT study.
The AFACT study was a single-center, prospective, randomized trial comparing efficacy and safety of additional GP ablation to PVI and left atrial lines in patients with advanced paroxysmal or persistent AF undergoing thoracoscopic surgery for AF. The study was registered at clinicaltrials.gov (NCT01091389) and approved by the Institutional Review Board of the Academic Medical Center. All patients provided written informed consent. The inclusion and exclusion criteria as well as the main clinical results have been published previously (13). In brief, patients 18 to 80 years of age with advanced AF undergoing thoracoscopic surgical ablation were eligible for inclusion. Advanced AF was defined as paroxysmal or persistent AF, with enlarged left atria or previously failed catheter ablation. Main exclusion criteria were prior catheter ablation within the preceding 4 months, New York Heart Association class IV heart failure, a history of radiation therapy on the thorax, and long-standing persistent AF. All patients (N = 240) were subjected to bilateral thoracoscopic PVI (≥6 radiofrequency applications to the PV antrum with the AtriCure Isolator Synergy bipolar radiofrequency ablation clamp [Mason, Ohio]). In patients with persistent AF, additional left atrial ablation lines were performed conforming to the Dallas lesion set (16,17). The left atrial appendage was excised using a stapler device. At the time of opening of the pericardium, patients were randomized to either additional ablation of the 4 major GP and Marshall ligament (n = 117) or no additional GP ablation (control group, n = 123). Evoked vagal responses were tested before and after GP and left atrial ablation in all patients. GP were localized based on anatomical landmarks as well as based on HFS-evoked response. In both groups, HFS of the 4 major GPs was repeated after all ablation was complete to confirm the absence or presence of a vagal response. Additional GP ablation was applied when necessary. As described previously (13), this method resulted in an absence of HFS-evoked vagal response in 100% of patients in the GP group, whereas a residual vagal response could be provoked in at least 1 GP in 87% of control patients (p < 0.001).
The efficacy and safety of GP ablation at 2-year follow-up was a pre-specified secondary endpoint of the AFACT study. Patients were followed for 2 years with outpatient visits, electrocardiograms (ECG) and 24-h Holter monitors at 3, 6, 9, 12, 15, 18, and 24 months. Patients were encouraged to obtain additional rhythm recording when symptomatic, and all recorded ECG and Holter data in referral hospitals were collected and included in the rhythm-monitoring analysis. AF recurrences were defined according to the definition in the Heart Rhythm Society/European Heart Rhythm Association/European Cardiac Arrhythmia Society consensus document, as were any episode of AF, atrial tachycardia, or atrial flutter documented on ECG or on 24-h Holter lasting >30 s (2).
A blanking period of 3 months after the procedure was instituted during which atrial tachyarrhythmia recurrences were not included in the clinical endpoints (1). After the blanking period, all antiarrhythmic drugs were discontinued, unless the patient remained to have AF. Anticoagulants were continued in all patients with a CHA2DS2-VASc (Congestive Heart Failure, Hypertension, Age ≥75 Years, Diabetes Mellitus, Prior Stroke or Transient Ischemic Attack or Thromboembolism, Vascular Disease, Age 65 to 74 Years, Sex) score ≥1 (unless solely based on female sex), irrespective of the (presumed) absence of AF or the exclusion of the left atrial appendage, and according to current guidelines (1). Procedural adverse events were defined as major when causing (prolongation of) hospital admission within 30 days.
The number of documented AF recurrences, paroxysmal and persistent, was assessed by the cumulative number of documented episodes of AF, atrial tachycardia, or atrial flutter documented on ECG or on 24-h Holter lasting >30 s per patient. Patients with an AF recurrence were categorized as: 1) a single AF recurrence; 2) some recurrences (1 to 3 episodes/year); or 3) many recurrences (>3 episodes/year or permanent AF) during follow-up. Recurrences requiring cardioversion or with spontaneous conversion were calculated similarly.
Randomization methods and the power calculation have been published before (13). Patients who were lost to follow-up were censored at the latest outpatient clinic visit. Continuous values were expressed as mean ± SD. Categorical variables were expressed as numbers and percentages. The Mann-Whitney U test, Wilcoxon signed-rank test, and Student’s t-test were used for comparisons. For the primary endpoint, freedom of AF recurrence, event-free survival was plotted and estimated by Kaplan-Meier curves. Intention-to-treat and per-protocol analyses were both performed. Repeated measurement analysis with mixed analysis of variance was used to compare heart rates recorded with 24-h Holter monitoring over time and paired Student’s t-test was used to compare heart rates at individual follow-up points with baseline heart rates. Clinical parameters associated with AF recurrence were studied using univariate and stepwise multivariate analysis in Cox proportional hazard models and expressed as hazard ratios (HRs) with corresponding 95% confidence intervals (CIs). A p value of <0.05 was considered statistically significant. Statistical analysis was performed with SPSS version 23.0, (IBM, Armonk, New York) and R (version 3.2.1 for Windows, R Foundation for Statistical Computing, Vienna, Austria).
Two-hundred-and-forty patients were randomized. Mean age at the time of the procedure was 59 ± 8 years, 73% were men, and mean left atrial volume index was 39 ± 12 ml/m2. Left atria were enlarged (>33 ml/m2) in 68% and severely enlarged (≥40 ml/m2) in 43% of patients. Fifty-six patients (23%) had 1 or more previous catheter ablations, and 143 patients (60%) had persistent AF. Baseline demographics are detailed in Table 1. In total, 228 patients (95%; GP ablation group n = 110; control group n = 118) completed follow-up. Two procedures were aborted (both in the GP ablation group), 4 patients died within the first year after the procedure (all in the GP ablation group, not procedure-related), and 6 patients were lost to follow-up at 2 years (1 in the GP ablation group, 5 in the control group).
Surgical procedure and complications
Procedural characteristics have been described previously (13). In short, PVI was performed in all patients. In the GP group, HFS-evoked vagal response was absent in 100% of patients, whereas residual vagal response could be provoked in 87% of patients without GP ablation (p < 0.001). Adverse events related to the procedure have also been published previously: clinically relevant sinus node dysfunction (12 vs. 4 patients; p = 0.038), procedural bleeding (9 vs. 0 patients; p < 0.001), and pacemaker implantation (6 vs. 0 patients; p = 0.013) were more frequent in patients allocated to GP ablation or control, respectively.
Aside from those, no procedural-related complications occurred during the second year of follow-up.
AF recurrences and treatment allocation
In the intention-to-treat analysis, freedom of any atrial tachyarrhythmia lasting longer than 30 s was 55.6% and 56.1% in the GP and control groups, respectively, after 2 years (log rank p = 0.91) (Figure 1A). Similarly, the per-protocol analysis resulted in a freedom of atrial tachyarrhythmias of 54.5% and 54.2% in the GP and control groups, respectively (log rank p = 0.96). Similar to the entire cohort, GP ablation did not affect freedom from AF in patients with paroxysmal AF (AF freedom in 70.7% vs. 66.1%, respectively; log rank p = 0.60) (Figure 2A), nor in patients with persistent AF (AF freedom in 50.0% vs. 47.8%, respectively; log rank p = 0.88) (Figure 2B). Despite recurrences in some, 78% of patients were not using antiarrhythmic medication at 2 years.
Seventy-five patients (31.2%) had their first AF recurrence during the first year of follow-up, 35 patients (29.9%) in the GP group and 40 (32.5%) in the control group. In another 29 patients (12.1%), AF recurred first in the second year of follow-up after thoracoscopic AF ablation, in 15 patients (12.2%) in the GP group and 14 patients (11.9%) in the control group. The lack of efficacy of GP ablation was consistent across subgroup analysis based on age, sex, AF type (i.e., paroxysmal or persistent AF), indexed left atrial volume, AF duration, CHA2DS2-VASc score, and history of previous catheter ablation for AF (Figure 3).
Type of atrial tachyarrhythmia recurrence
During 2-year follow-up, 104 patients had atrial tachyarrhythmia recurrences, of which 53 (51%) were atrial tachycardia (AT) and 51 (49%) were AF recurrences (p = 0.85). In the GP group, numerically more recurrences of AT (n = 30) than AF (n = 20) occurred (p = 0.16), whereas there was a trend toward the opposite relation in the control group, AT (n = 23) versus AF (n = 31; p = 0.28).
During the second year of follow-up, there were 9 AT compared with 6 AF recurrences in the GP group (p = 0.44). In the control group, more AT (n = 10) than AF (n = 4) recurrences were documented, although they were not significantly different (p = 0.11).
Documented atrial tachyarrhythmia recurrences
The number of documented AF recurrence after thoracoscopic surgical AF ablation is displayed in Figure 1B. After 2 years, 11.4% of the total study population had >3 AF recurrences per year or permanent AF, 11.8% in the GP group versus 11.0% in the control group (p = 0.82). This was mainly driven by patients with persistent AF, of whom 17.0% had >3 AF recurrences or permanent AF, 14.1% in the GP group versus 20.3% in the control group (p = 0.32) (Figure 4A). More than 3 AF recurrences or permanent AF occurred in 3.2% of patients with paroxysmal AF at randomization, 7.7% in the GP group versus 0% in the control group (p = 0.02) (Figure 4B). The percentage of patients with a single or some recurrences was similar in both treatment groups (p = 0.73). The recurrences were mostly recorded on ECG (65.4%), which included ECG during standard follow-up (28.9%) and indicated by symptoms (71.1%), whereas in 34.6%, the recurrences were recorded by Holter monitoring.
Predictors of AF recurrence
Figure 5 shows the univariate and multivariate analysis of clinical determinants of AF recurrence, regardless of randomization. AF type (i.e., paroxysmal or persistent AF) at the time of surgery was independently associated with AF recurrence (HR: 1.44; 95% CI: 1.12 to 2.67; p = 0.01). Also, left atrial volume index (classified as <33 ml/m2, 34 to 40 ml/m2 or >40 ml/m2) was independently associated with AF recurrence (HR: 1.28; 95%: 1.00 to 1.64; p = 0.04). Age, history of previous PVI and CHA2DS2-VASc scores were associated with AF recurrence in univariate analysis, but this association did not hold in multivariate analysis.
Effect of GP ablation on heart rate
In a repeated measurement analysis, the mean heart increased significantly over time (F [4.39, 487.50] = 2.46, p=0.04). There was no interaction between the change in heart rate over time and randomization group (p = 0.61).
Also, the maximum and minimum heart rate changed significantly over time (F4.83, 564.95 = 12.47, p < 0.01 and F5.22, 615.58 = 35.00, p < 0.01, respectively), independent of randomization (p = 0.88 and p = 0.46, respectively).
At individual follow-up points, only at the 9-month follow-up was the mean heart rate significantly higher in the GP ablation group (76.0 ± 12.4 vs. 79.5 ± 10.3 in the control group, p = 0.04) (Table 2). Meanwhile, the minimal heart rate at individual follow-up points was numerically higher in the GP group, although this was only significant at 9-month follow-up (59.0 ± 9.3 vs. 56.0 ± 10.9 in the control group, p = 0.04) (Table 2). Maximally achieved heart rate was similar between the GP and control groups at all follow-up points.
Table 3 displays the change of heart rate at individual follow-up points compared with baseline in a paired analysis. In the GP ablation group, mean heart rate was significantly higher compared with baseline rate at 6 and 9 months (both p < 0.01). These differences did not persist over the duration of the follow-up. In the control group, there was no significant difference in mean heart rate at follow-up points compared with baseline rate. However, the minimum heart rate increased in both groups, and at the same time, the maximum heart rate decreased significantly.
The AFACT study was the first randomized study investigating the benefit of additional GP ablation in patients with advanced AF undergoing thoracoscopic surgery (13). Here we present the intermediate-term efficacy and safety outcomes.
AF recurrence by treatment allocation
Similar to the results of the main publication at 1 year, additional GP ablation does not reduce AF recurrences during 2 years of follow-up. This is regardless of AF type at randomization, although patients with paroxysmal AF had fewer AF recurrences than patients with persistent AF did. This is in contrast to earlier studies on GP ablation in addition to PVI, which concluded that the treatment effects increase over time (10,18). It has been suggested that heterogeneity of patient characteristics within our study, for example, inclusion of both patients with paroxysmal AF and persistent AF, and patients with prior catheter ablation might have caused a neutral effect at 1 year of follow-up, which plausibly could be different at longer follow-up (19). Nevertheless, our results demonstrate no difference in AF recurrence during longer follow-up. Also, subgroup analysis did not reveal a subpopulation with potential beneficial (or detrimental) effect of GP ablation on AF.
Importantly, the thoracoscopic approach toward GP ablation differs from catheter techniques, as it reaches to the GP from the epicardium. This may allow for better localization and exposure of GP when compared with endocardial catheter ablation. In the latter approach, the GP cannot be ablated without concomitantly ablating the myocardium in between the endocardial catheter and the epicardially located GP. It cannot be excluded that the better outcome of additional GP ablation reported by Katritsis et al. (10) is partially the consequence of more thorough PVI, as total ablation time was indeed significantly longer in the GP + PVI group. In the present study, both anatomic landmarks (i.e., epicardial fat pads) and HFS were used to localize the GP. All ablation lines and efficacy of GP ablation were thoroughly confirmed using entry and exit block, differential pacing, and repeat HFS of the areas of the GP, as previously described (20). After GP ablation, HFS-evoked vagal response was indeed absent in 100% of the patients. In patients not allocated to GP ablation, a vagal response could still be evoked in 87% of patients (p < 0.001).
The lack of efficacy of GP ablation may also be due to a more progressed AF substrate. Patients included in the present study had advanced AF and their arrhythmogenic substrates may have been different to those in patients with paroxysmal AF in whom a benefit of additional GP ablation was demonstrated earlier (10). In patients with advanced AF, progressed atrial remodeling may even be associated with a proarrhythmogenic effect when subjected to GP ablation (11,12). It is similarly likely that autonomic modification adds little in already progressed autonomic, electrical, and structural remodeling of the atrium. Furthermore, PVI itself may block the possibility for the GP to trigger the PV firing and therefore reduces the risk for AF in both study groups (21).
Number of documented AF recurrences
We report that the number of documented AF recurrences, measured as number of AF recurrences per year, was generally low and similar between patients who underwent additional GP ablation compared with the control subjects. This is consistent with an earlier report on long-term outcome of thoracoscopic ablation in advanced AF (22). A substantial part of the patients in whom thoracoscopic ablation was unsuccessful according to the consensus criteria of outcome definition, had fewer than 1 documented episode per year (i.e., only 1 episode in total) of recurrent AF at 2-year follow-up. Of note, we did not quantify the number of documented AF episodes before the intervention, because such an analysis would require estimation of days in AF rather than the number of episodes. Furthermore, we did not perform continuous monitoring during follow-up, but collected all rhythm recordings that were performed in a comprehensive follow-up. In addition, we collected all recordings performed during visits because of symptoms, while realizing that short, asymptomatic AF episodes may have been missed using this method. Whereas all patients were highly symptomatic before thoracoscopic surgery, merely 11% of the patients remained to have frequent, symptomatic, recurrences after treatment. It can be advocated that, reporting a measure of AF burden is clinically more meaningful than a Kaplan-Meier representation of the results, as advocated by the Heart Rhythm Society/European Heart Rhythm Association/European Cardiac Arrhythmia Society consensus document (2). Indeed, assigning the same weight to a single episode of 31 s, as to the development of permanent AF, underestimates the clinical impact AF recurrences may have. Aside from that, the main indication for invasive treatment of AF is formed by reducing AF-related symptoms. We have previously shown in the same cohort that patients with a single recurrence of AF have the same improvement in quality of life as patients without a recurrence, whereas multiple recurrences are associated with lack of quality of life improvement (22). The clinical implication of a single or few AF recurrences is further underscored by the observation that a high percentage, 78%, of patients had discontinued antiarrhythmic drugs at 2 years of follow-up. Importantly, as there is no consequence for the discontinuation of anticoagulation in patients with a presumed successful ablation, health-related quality of life and medication use are relevant clinical outcomes.
Role of additional left atrial lesions
AF recurrences were more prevalent in patients with persistent AF at randomization than in those with paroxysmal AF. This may be due to a more progressed substrate, but also the ablation strategy was different. Patients with paroxysmal AF were treated with epicardial PVI alone, whereas a roof (superior) line and trigone line were ablated in patients with persistent AF. Conduction block across these lines was confirmed with pacing maneuvers, but evidently acute block does not per se predict persistence of conduction block over time. Also, there were patients with confirmed lack of conduction block due to anatomical restrictions. Aside from that, there remains discussion on the optimal ablation strategy in persistent AF patients, as STAR-AF II demonstrated that additional ablation of GP, complex fractionate atrial electrograms, or left atrial lines was not associated with better outcome than PVI alone (3). Also, it has been demonstrated that more lines are associated with a higher chance of reconnection along any of those lines (23). Hence, the optimal lesion set in these patients remains to be determined.
Evidence for autonomic modification during intermediate-term follow-up
It has been suggested that parasympathetic denervation may recover due to atrial neural resprouting and hyper reinnervation (8,24). This has been demonstrated in humans and confirmed by imaging (25). We did not test for reinnervation during follow-up; however, we found similar heart rates at 1 and 2 years in both groups, after an initial significantly increased heart rate in the GP group at 6 and 9 months. This suggests that the effect of GP ablation is diminished on the long term, which may point at reinnervation of the GP or other adaptive mechanisms. Contrary to that observation, minimum heart rate was numerically, but not significantly higher, in the GP group during the complete follow-up, which also holds for the control group. Furthermore, the decrease in maximum heart rate was less in the GP ablation group than in the control group. Of note, the changes in heart rate may also be in part due to the discontinuation of antiarrhythmic medication, including beta-blockers from 3 months of follow-up onward in both groups.
In addition to the previously published procedural complications, no further adverse effects that could be attributed to the procedure or strategy were encountered during the second year of follow-up. However, during the first year, GP ablation was associated with more major complications (19% vs. 8%) (13).
The number of documented episodes of AF recurrences was assessed, but the study protocol did not include continuous rhythm monitoring. Hence, the actual AF burden may have been underestimated, most importantly with regard to asymptomatic episodes of AF. However, serial rhythm monitoring by at least 7 24-h Holter monitors was conducted as demanded in the study. The chosen approach did allow for a symptom-driven calculation of the AF burden, as well as an estimation of asymptomatic episodes, as 53.4% of recurrent AF episodes were captured on standardly performed ECG or Holter monitoring. Of note, the amount and duration of rhythm monitoring used in the present study comprises a comprehensive follow-up, beyond what the guidelines recommend following AF surgery (2).
Next, it was not possible to assess burden of AF at baseline, because that would have required a strategy of determining the days in AF to avoid a single episode of AF of minutes-long duration being counted similarly as an ongoing episode for months. This made a definite comparison of AF burden before and after surgery impossible.
GP ablation added to PVI and left atrial lines during thoracoscopic AF surgery does not affect 2-year freedom of AF recurrence. Documented AF recurrences during 2 years of follow-up were very modest (maximum of 3 AF recurrences per year) in almost 90% of patients and were not different among patients with or without GP ablation. The increased heart rate induced by GP ablation normalized after more than 9 months of follow-up. Major procedural complications occurred more frequently in patients assigned to GP ablation, but there were no further complications during follow-up. Hence, and in the absence of benefit, ablation of the GP should not routinely be performed.
COMPETENCY IN MEDICAL KNOWLEDGE: PVI is the cornerstone in the invasive treatment of AF, but may be insufficient for persistent or advanced AF (that is, usually persistent in nature, with enlarged left atria or previously failed catheter ablation). Autonomic modulation through ablation of the GP has been proposed as an additional ablation target.
TRANSLATIONAL OUTLOOK 1: In patients with advanced AF undergoing thoracoscopic PVI, additional GP ablation did not improve freedom of AF recurrence. However, thoracoscopic PVI resulted in very modest burden of AF in almost 90% of patients, irrespective of GP ablation.
TRANSLATIONAL OUTLOOK 2: Importantly, GP ablation resulted in more major procedural complications. Hence, and in the absence of benefit, ablation of the GP should not routinely be performed.
↵∗ Drs. Berger and Neefs contributed equally to this work and are joint first authors.
Dr. Driessen is a proctor and consultant for AtriCure. Dr. Van Boven is a consultant for AtriCure. Dr. de Groot received a VIDI grant (106.146.310) from Netherlands Organization for Health and Research Development/Netherlands Organization for Scientific Research (ZonMW/NWO); research grants from AtriCure, Medtronic, Abbott, and Boston Scientific; and is a consultant for Daiichi-Sankyo, AtriCure, Bayer, and Novartis. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
All authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- Abbreviations and Acronyms
- atrial fibrillation
- atrial tachycardia
- confidence interval
- ganglion plexus
- high-frequency stimulation
- hazard ratio
- pulmonary vein
- pulmonary vein isolation
- Received August 13, 2018.
- Revision received October 15, 2018.
- Accepted October 16, 2018.
- 2019 The Authors
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