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Repeat Atrial Fibrillation Ablation Procedures in the CIRCA-DOSE Study

2020; Lippincott Williams & Wilkins; Volume: 13; Issue: 9 Linguagem: Inglês

10.1161/circep.120.008480

1941-3149

Christopher C. Cheung, Marc W. Deyell, Laurent Macle, Atul Verma, Jean Champagne, Peter Leong‐Sit, Paul Novak, Mariano Badra‐Verdu, John L. Sapp, Paul Khairy, Jason G. Andrade,

Cardiac electrophysiology and arrhythmias

HomeCirculation: Arrhythmia and ElectrophysiologyVol. 13, No. 9Repeat Atrial Fibrillation Ablation Procedures in the CIRCA-DOSE Study Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessLetterPDF/EPUBRepeat Atrial Fibrillation Ablation Procedures in the CIRCA-DOSE Study Christopher C. Cheung, MD Marc W. Deyell, MD, MSc Laurent Macle, MD Atul Verma, MD Jean Champagne, MD Peter Leong-Sit, MD Paul Novak, MD Mariano Badra-Verdu, MD John Sapp, MD Paul Khairy, MD, PhD Jason G. AndradeMD Christopher C. CheungChristopher C. Cheung Department of Medicine, University of British Columbia, Vancouver, Canada (C.C.C., M.W.D., J.G.A.). , Marc W. DeyellMarc W. Deyell https://orcid.org/0000-0001-8434-7076 Department of Medicine, University of British Columbia, Vancouver, Canada (C.C.C., M.W.D., J.G.A.). Center for Cardiovascular Innovation, Vancouver, Canada (M.W.D., J.G.A.). , Laurent MacleLaurent Macle https://orcid.org/0000-0002-3328-5239 Montreal Heart Institute, Department of Medicine, Université de Montréal, Canada (L.M., P.K., J.G.A.). , Atul VermaAtul Verma https://orcid.org/0000-0002-1020-9727 Southlake Regional Health Center, Newmarket, Canada (A.V.). , Jean ChampagneJean Champagne https://orcid.org/0000-0001-9861-9351 Université Laval, Quebec City, Canada (J.C.). , Peter Leong-SitPeter Leong-Sit University of Western Ontario, London, Canada (P.L.-S.). , Paul NovakPaul Novak Royal Jubilee Hospital, Victoria, Canada (P.N.). , Mariano Badra-VerduMariano Badra-Verdu https://orcid.org/0000-0002-2222-801X Centre Hospitalier Universitaire de Sherbrooke, Canada (M.B.-V.). , John SappJohn Sapp https://orcid.org/0000-0002-9602-2751 Queen Elizabeth II Health Sciences Centre & Dalhousie University, Halifax, Canada (J.S.). , Paul KhairyPaul Khairy https://orcid.org/0000-0003-4059-3800 Montreal Heart Institute, Department of Medicine, Université de Montréal, Canada (L.M., P.K., J.G.A.). , Jason G. AndradeJason G. Andrade Correspondence to: Jason Andrade, MD, Vancouver General Hospital, 2775 Laurel St, Vancouver, BC V5Z 1M9, Canada. Email E-mail Address: [email protected] https://orcid.org/0000-0002-8493-5123 Department of Medicine, University of British Columbia, Vancouver, Canada (C.C.C., M.W.D., J.G.A.). Center for Cardiovascular Innovation, Vancouver, Canada (M.W.D., J.G.A.). Montreal Heart Institute, Department of Medicine, Université de Montréal, Canada (L.M., P.K., J.G.A.). Originally published23 Jul 2020https://doi.org/10.1161/CIRCEP.120.008480Circulation: Arrhythmia and Electrophysiology. 2020;13:e008480Pulmonary vein (PV) isolation remains the cornerstone of atrial fibrillation (AF) ablation procedures owing to its ability to target AF-initiating triggers as well as the electrically active left atrial myocardial tissue capable of sustaining the AF-perpetuating fibrillatory wavelets. While electrical PV isolation may be acutely achieved, failure to realize durable lesions around the PVs leads to conduction recovery and arrhythmia recurrence.1 Technological advances designed to improve lesion durability include the integration of contact-force assessment into radiofrequency catheters (CF-RF) and the development of single-shot cryoballoon catheters.The CIRCA-DOSE study (Cryoballoon vs Irrigated Radiofrequency Catheter Ablation: Double Short vs Standard Exposure Duration; URL: https://www.clinicaltrials.gov; Unique identifier: NCT01913522) was a multicentre randomized trial evaluating the safety and efficacy of these advanced-generation AF ablation technologies in patients with drug-refractory paroxysmal AF.2 The study demonstrated that PV isolation performed by second generation cryoballoon or by CF-RF resulted in comparable freedom from atrial tachyarrhythmia, as measured by continuous cardiac monitoring using an implantable loop recorder.3 This report focuses on patients who underwent repeat ablation procedures for symptomatic atrial tachyarrhythmia, with the objective of evaluating PV reconnections.This study had received institutional research board approval, and all subjects provided informed consent. For continuous variables, descriptive statistics were presented using mean±SD or median (Q1–Q3) according to the distribution. For categorical variables, number and percentages were presented. Group comparisons for continuous variables, such as arrhythmia burden, were analyzed using Mann-Whitney tests. For dichotomous qualitative variables, χ2 tests were performed to assess group differences. The data that support the findings of this study are available from the corresponding author upon reasonable request.Among the 346 patients randomized in the CIRCA-DOSE trial, 52 patients (15%) underwent a repeat ablation procedure following documented recurrence of symptomatic atrial tachyarrhythmia. There were no significant differences in baseline characteristics between participants undergoing repeat ablation and the remaining cohort, apart from a higher baseline AF burden (percent time in AF) in those who underwent a repeat procedure (10.1% [interquartile range, 0.7–22.5] versus 1.6% [0.1–9.9], P=0.002). After the index ablation procedure, patients undergoing a repeat procedure had a lower quality-of-life (Atrial Fibrillation Effect on Quality-of-life Questionnaire score, 76.9 [58.1–93.8] versus 93.5 [82.4–99.0], P<0.0001) and a smaller reduction in AF burden compared with the remaining cohort (76.4% [10.2–95.0] versus 100.0% [87.7–100.0], P<0.0001).There was no significant difference in the rate of repeat procedures between the CF-RF (16 patients), short-duration cryoballoon ablation (CRYO-2, 18 patients), and standard-duration cryoballoon ablation groups (CRYO-4, 18 patients, P=0.92).The repeat ablation procedure was performed a median of 225 days (164.3–285.5) following the index ablation. At the discretion of the treating physician, CF-RF was used in 49 repeat procedures. The duration of the repeat procedure was significantly shorter than the index procedure (103.0 [74.0–130.0] versus 133.5 minutes [106.3–280.0], P=0.0003), which remained significant in the subgroup of patients randomized to CF-RF for their index procedure (101.0 [77.75–141.0] versus 162.5 minutes [126.5–188.5], P=0.001). Fluoroscopy time was shorter in the repeat procedure (4.9 [2.5–9.2] versus 16.1 minutes [6.9–26.2], P<0.0001); however, there was no significant difference when the analysis was restricted to patients who underwent CF-RF for both procedures (5.9 [2.8–8.9] versus 6.7 minutes [4.6–12.9], P=0.49).At the repeat procedure, PV reconnection was noted in 47/52 (90.4%) patients, with no significant differences between groups (14/16 [87.5%] after CF-RF, 17/18 [94.4%] after CRYO-4, and 16/18 [88.9%] after CRYO-2, P=0.64). The median number of reconnected PVs per patient was 2 (1–2) after CF-RF, 2 (1–3) after CRYO-2, and 1 (1–2) after CRYO-4 (P=0.46).A total of 89/201 PVs (44.3%) were reconnected (Figure). This included 23/52 (44.2%) right superior, 27/52 (51.9%) right inferior, 17/42 (40.5%) left superior, 15/42 (35.7%) left inferior, 1/3 (33.3%) right middle, and 6/10 (60.0%) left common PVs. There was no difference in the pattern of reconnection between the CF-RF and cryoballoon groups (Figure).Download figureDownload PowerPointFigure. Rates of reconnection with contact-force radiofrequency and cryoballoon ablation, stratified by pulmonary vein. CF-RF indicates contact-force radiofrequency; CRYO, cryoballoon ablation; and PV, pulmonary vein.In this contemporary randomized trial comparing advanced-generation ablation technologies, there was no significant difference in the proportion of patients undergoing a repeat ablation procedure, nor any difference in the rate or regionalization of PV reconnection between CF-RF and cryoballoon ablation. These findings are in contrast to the FIRE AND ICE trial (Cryoballoon or Radiofrequency Ablation for Paroxysmal Atrial Fibrillation), which randomized 762 patients in a 1:1 ratio to predominantly noncontact-force RF ablation and cryoballoon ablation.4 In the FIRE AND ICE repeat ablation study, 15% of patients underwent a repeat ablation procedure. In the 81% of patients with available repeat ablation data, there was a significantly greater number of reconnected PVs per patients after RF ablation when compared with cryoballoon ablation (2.1±1.4 versus 1.4±1.1, P=0.010).4 Moreover, the authors noted a higher incidence of reconnection in the left superior PV with RF ablation compared with cryoablation (60% versus 28%, P=0.01).The discrepancy between the CIRCA-DOSE and FIRE AND ICE studies may be related to the use of CF-RF ablation catheters, which were universally employed in CIRCA-DOSE but used in only a minority of patients in FIRE AND ICE. Contact-force catheters would be expected to improve lesion delivery, particularly across the left lateral ridge, which is known to be associated with lower contact force and catheter stability.5 As such, the current analysis of the CIRCA-DOSE trial provides support for both contact-force RF and second-generation cryoballoon ablation catheters for PV isolation in patients with paroxysmal AF. Nevertheless, despite advances in ablation technology, PV reconnection remains a clinically relevant issue.Nonstandard Abbreviations and AcronymsAFatrial fibrillationCF-RFcontact-force radiofrequencyCIRCA-DOSECryoballoon vs Irrigated Radiofrequency Catheter Ablation: Double Short vs Standard Exposure DurationCRYOcryoballoon ablationFIRE AND ICECryoballoon or Radiofrequency Ablation for Paroxysmal Atrial FibrillationPVpulmonary veinSources of FundingThe CIRCA-DOSE study was funded by a peer-reviewed grant from the Heart and Stroke Foundation of Canada [grant number G-13-0003121], with additional financial support from Medtronic. Drs Andrade and Deyell are supported by a Michael Smith Foundation for Health Research Scholar Award. Dr Khairy is supported by the André Chagnon research chair in electrophysiology and congenital heart disease. The funding sources had no role in the design of this study and did not have any role during its execution, analyses, interpretation of the data, or decision to submit results.DisclosuresDr Andrade reports grants and personal fees from Medtronic, grants from Baylis, personal fees from Biosense-Webster; Dr Verma reports grants and personal fees from Medtronic, and Biosense-Webster; Dr Deyell reports grants from Biosense-Webster; Dr Leong-Sit reports personal fees from Medtronic, personal fees from Biosense-Webster; Dr Sapp reports grants and personal fees from Biosense-Webster, grants and personal fees from St. Jude Medical/Abbott, personal fees from Medtronic; and Dr Macle reports personal fees from Medtronic, grants and personal fees from St. Jude Medical/Abbott and Biosense-Webster. The other authors report no conflicts.FootnotesFor Sources of Funding and Disclosures, see page 1035.Correspondence to: Jason Andrade, MD, Vancouver General Hospital, 2775 Laurel St, Vancouver, BC V5Z 1M9, Canada. Email jason.[email protected]caReferences1. Verma A, Kilicaslan F, Pisano E, Marrouche NF, Fanelli R, Brachmann J, Geunther J, Potenza D, Martin DO, Cummings J, et al.. Response of atrial fibrillation to pulmonary vein antrum isolation is directly related to resumption and delay of pulmonary vein conduction.Circulation. 2005; 112:627–635. doi: 10.1161/CIRCULATIONAHA.104.533190LinkGoogle Scholar2. Andrade JG, Deyell MW, Badra M, Champagne J, Dubuc M, Leong-Sit P, Macle L, Novak P, Roux JF, Sapp J, et al.. Randomised clinical trial of cryoballoon versus irrigated radio frequency catheter ablation for atrial fibrillation-the effect of double short versus standard exposure cryoablation duration during pulmonary vein isolation (CIRCA-DOSE): methods and rationale.BMJ Open. 2017; 7:e017970. doi: 10.1136/bmjopen-2017-017970MedlineGoogle Scholar3. Andrade JG, Champagne J, Dubuc M, Deyell MW, Verma A, Macle L, Leong-Sit P, Novak P, Badra-Verdu M, Sapp J, et al.; CIRCA-DOSE Study Investigators. . Cryoballoon or radiofrequency ablation for atrial fibrillation assessed by continuous monitoring: a randomized clinical trial.Circulation. 2019; 140:1779–1788. doi: 10.1161/CIRCULATIONAHA.119.042622LinkGoogle Scholar4. Kuck KH, Albenque JP, Chun KJ, Fürnkranz A, Busch M, Elvan A, Schlüter M, Braegelmann KM, Kueffer FJ, Hemingway L, et al.. FIRE AND ICE Investigators. . Repeat ablation for atrial fibrillation recurrence post cryoballoon or radiofrequency ablation in the FIRE AND ICE trial.Circ Arrhythm Electrophysiol. 2019; 12:e007247. doi: 10.1161/CIRCEP.119.007247LinkGoogle Scholar5. Reddy VY, Shah D, Kautzner J, Schmidt B, Saoudi N, Herrera C, Jaïs P, Hindricks G, Peichl P, Yulzari A, et al.. The relationship between contact force and clinical outcome during radiofrequency catheter ablation of atrial fibrillation in the TOCCATA study.Heart Rhythm. 2012; 9:1789–1795. doi: 10.1016/j.hrthm.2012.07.016CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited BySørensen S, Johannessen A, Worck R, Hansen M and Hansen J (2021) Radiofrequency Versus Cryoballoon Catheter Ablation for Paroxysmal Atrial Fibrillation: Durability of Pulmonary Vein Isolation and Effect on Atrial Fibrillation Burden: The RACE-AF Randomized Controlled Trial, Circulation: Arrhythmia and Electrophysiology, 14:5, Online publication date: 1-May-2021. September 2020Vol 13, Issue 9Article InformationMetrics Download: 201 © 2020 American Heart Association, Inc.https://doi.org/10.1161/CIRCEP.120.008480PMID: 32701361 Originally publishedJuly 23, 2020 Keywordspulmonary veinfreedomatrial fibrillationheart atriainformed consentPDF download