Effectiveness Study of Circumferential vs. Segmental Ablation in Paroxysmal Atrial Fibrillation (PAF)
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|ClinicalTrials.gov Identifier: NCT02106663|
Recruitment Status : Active, not recruiting
First Posted : April 8, 2014
Last Update Posted : October 15, 2018
|Condition or disease||Intervention/treatment||Phase|
|Paroxysmal Atrial Fibrillation Atrial Arrhythmia||Procedure: Circumferential Pulmonary Vein Ablation Procedure: Segmental Pulmonary Vein Isolation||Not Applicable|
Despite more than a decade of clinical experience and investigation, the optimal approach to ablation of paroxysmal atrial fibrillation (PAF) still remains controversial. There are currently two strategies for ablation of PAF: (1) circumferential pulmonary vein ablation (CPVA) and (2) segmental pulmonary vein isolation (SPVI). There are advantages and disadvantages associated with each method. In the CPVA method (1), contiguous ablation lesions are created to encircle the two left and right pulmonary veins (PVs), guided by a three-dimensional (3D) electroanatomic mapping system (Carto, Biosense Webster, Inc. or ESI NavX, St. Jude, Inc.) with a 3D left atrial (LA) geometry created either by using the mapping catheter or by importing a pre-recorded 3D computed tomography (CT) image. In the SPVI method (2), electrical potentials recorded at the PV ostium, that represent myocardial connections between the LA and PVs, are ablated at the PV ostium or just proximal to the PV ostium in the PV antrum. In this approach, ablation is performed segmentally at multiple sites around the PV ostium or antrum, until mapping with a circular catheter demonstrates pulmonary vein isolation.
The reported success rates for SPVI for prevention of recurrence of PAF range from 60-87% (2-4) with most recurrences associated with recovery of PV conduction. Therefore, the success of SPVI for treatment of PAF appears to be related to in large part to permanent elimination of the triggers of AF. In a retrospective study by Sawhney et al, overall 5-year outcome after SPVI for PAF was similar to that for short-term follow up less than or equal to 2 years. However, late recurrences after 2 years did occur (up to 22.5%) and repeat ablation was often required to maintain freedom from symptomatic PAF (5).
Even though success rates for CPVA have been reported to be higher (up to 90%), most CPVA procedures previously reported included left atrial linear ablation (LALA), additional ablation lesions or lines connecting the mitral valve to the posterior pulmonary veins or along the roof of the left atrium. Thus the success of CPVA may be due in part to ablation of substantially larger amounts of atrial tissue (6-7). However, additional ablation (LALA) may cause potential pro-arrhythmic effects that lead to development of atypical left atrial flutter (8).
Compared to SPVI, CPVA resulted in higher success rates and lower fluoroscopy time in one study by Arentz et al (9). However, that study included subjects with both PAF and persistent AF, and those with persistent AF have potentially different underlying mechanisms. Furthermore, two other randomized studies comparing the efficacy of PVI and CPVA have shown conflicting results (10-11).
Thus, we will initiate this randomized controlled study to evaluate the efficacy of CPVA versus SPVI in subjects undergoing ablation of paroxysmal atrial fibrillation only.
|Study Type :||Interventional (Clinical Trial)|
|Estimated Enrollment :||100 participants|
|Intervention Model:||Parallel Assignment|
|Masking:||None (Open Label)|
|Official Title:||Evaluating the Efficacy of Circumferential Pulmonary Vein Ablation (CPVA) Versus Segmental Pulmonary Vein Isolation (SPVI) in Paroxysmal Atrial Fibrillation|
|Actual Study Start Date :||July 2012|
|Estimated Primary Completion Date :||November 2019|
|Estimated Study Completion Date :||May 2020|
Active Comparator: Circumferential Pulmonary Vein Ablation
Contiguous ablation lesions will be performed to encircle the two left and right pulmonary veins (PVs), guided by 3D electroanatomic mapping (Carto, Biosense Webster, Inc. or ESI NavX, St. Jude, Inc.) with a 3D LA geometry created either by using the roving mapping catheter or by importing a pre-recorded 3D CT image of the left atrium. After completion of the circumferential ablation, PV isolation will be confirmed by the mapping catheter, and further focal ablation performed as required until electrical PV isolation is confirmed (entrance block at a minimum).
Procedure: Circumferential Pulmonary Vein Ablation
Contiguous ablation lesions will be performed to encircle the two left and right pulmonary veins (PVs) of the left atrium, guided by 3D electroanatomic mapping. After completion of the circumferential ablation, PV isolation will be confirmed by the mapping catheter, and further focal ablation performed as required until electrical PV isolation is confirmed.
Active Comparator: Segmental Pulmonary Vein Isolation
Electrical potentials recorded in the pulmonary vein (PV) ostium using a circular mapping catheter, representing myocardial connections between the left atrium and PVs will be ablated at or just proximal to the PV ostium in the PV antrum. Ablation will be performed segmentally at multiple sites guided by the mapping catheter around the PV ostium or antrum, until mapping demonstrates elimination of all PV potentials (entrance block at a minimum).
Procedure: Segmental Pulmonary Vein Isolation
Electrical potentials recorded in the pulmonary vein (PV) ostium using a circular mapping catheter, representing electrical connections between the left atrium and PVs will be ablated at or just proximal to the PV ostium in the PV antrum. Ablation will be performed segmentally at multiple sites guided by the mapping catheter until mapping demonstrates elimination of all PV potentials.
- Atrial Fibrillation Recurrence [ Time Frame: 2 years ]Recurrence of atrial fibrillation (AF) will be defined as any ECG documented symptomatic AF, or asymptomatic AF lasting >30 seconds on Mobile Outpatient Cardiac Telemetry (MCOT) monitoring. Subjects will be scheduled for clinic visits at 1, 6, 12 and 24 months post ablation. In addition, mobile outpatient telemetry will be performed for at least seven days at 6, 12 and 24 months post-procedure to detect recurrence of asymptomatic atrial fibrillation.
- Pulmonary Vein Stenosis [ Time Frame: 3 Months ]A CT scan of the left atrium and pulmonary veins will be routinely performed 3 months after ablation to assess for any evidence of pulmonary vein stenosis
To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.
Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT02106663
|United States, California|
|UCSD Sulpizio Cardiovascular Center|
|La Jolla, California, United States, 92093|
|Principal Investigator:||Gregory K Feld, MD||University of California, San Diego|