A randomized trial of circumferential pulmonary vein ablation versus antiarrhythmic drug therapy in paroxysmal atrial fibrillation: the APAF Study.
OBJECTIVE
We compared ablation strategy with antiarrhythmic drug therapy (ADT) in patients with paroxysmal atrial fibrillation (PAF).


BACKGROUND
Atrial fibrillation (AF) ablation strategy is superior to ADT in patients with an initial history of PAF, but its role in patients with a long history of AF as compared with ADT remains a challenge.


METHODS
One hundred ninety-eight patients (age, 56 +/- 10 years) with PAF of 6 +/- 5 years' duration (mean AF episodes 3.4/month) who had failed ADT were randomized to AF ablation by circumferential pulmonary vein ablation (CPVA) or to the maximum tolerable doses of another ADT, which included flecainide, sotalol, and amiodarone. Crossover to CPVA was allowed after 3 months of ADT.


RESULTS
By Kaplan-Meier analysis, 86% of patients in the CPVA group and 22% of those in the ADT group who did not require a second ADT were free from recurrent atrial tachyarrhythmias (AT) (p < 0.001); a repeat ablation was performed in 9% of patients in the CPVA group for recurrent AF (6%) or atrial tachycardia (3%). At 1 year, 93% and 35% of the CPVA and ADT groups, respectively, were AT-free. Ejection fraction, hypertension, and age independently predicted AF recurrences in the ADT group. Circumferential pulmonary vein ablation was associated with fewer cardiovascular hospitalizations (p < 0.01). One transient ischemic attack and 1 pericardial effusion occurred in the CPVA group; side effects of ADT were observed in 23 patients.


CONCLUSIONS
Circumferential pulmonary vein ablation is more successful than ADT for prevention of PAF with few complications. Atrial fibrillation ablation warrants consideration in selected patients in whom ADT had already failed and maintenance of sinus rhythm is desired. (A Controlled Randomized Trial of CPVA Versus Antiarrhythmic Drug Therapy in for Paroxysmal AF: APAF/01; http://clinicaltrials.gov/ct/show; NCT00340314).
Pappone
Carlo
C
Division of Cardiac Pacing and Electrophysiology, San Raffaele University Hospital, Milan, Italy. carlo.pappone@hsr.it
Augello
Giuseppe
G
Sala
Simone
S
Gugliotta
Filippo
F
Vicedomini
Gabriele
G
Gulletta
Simone
S
Paglino
Gabriele
G
Mazzone
Patrizio
P
Sora
Nicoleta
N
Greiss
Isabelle
I
Santagostino
Andreina
A
LiVolsi
Laura
L
Pappone
Nicola
N
Radinovic
Andrea
A
Manguso
Francesco
F
Santinelli
Vincenzo
V
D000367:Age Factors; D000368:Aged; D000638:Amiodarone / Q000627:therapeutic use; D000889:Anti-Arrhythmia Agents / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000150:complications / Q000188:drug therapy* / Q000503:physiopathology / Q000601:surgery*; D002318:Cardiovascular Diseases / Q000209:etiology / Q000628:therapy; D017115:Catheter Ablation / Q000009:adverse effects; D004305:Dose-Response Relationship, Drug; D005260:Female; D005424:Flecainide / Q000627:therapeutic use; D005500:Follow-Up Studies; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D006973:Hypertension / Q000150:complications; D053208:Kaplan-Meier Estimate; D008297:Male; D008499:Medical Records; D008875:Middle Aged; D011379:Prognosis; D011667:Pulmonary Veins / Q000601:surgery*; D019233:Retreatment; D013015:Sotalol / Q000627:therapeutic use; D013318:Stroke Volume; D017211:Treatment Failure
D000889:Anti-Arrhythmia Agents; D013015:Sotalol; D005424:Flecainide; D000638:Amiodarone