Atrial Fibrillation Catheter Ablation Versus Surgical Ablation Treatment (FAST): A 2-Center Randomized Clinical Trial

Study Questions:

Is minimally-invasive surgical ablation (SA) more effective than radiofrequency catheter ablation (RFCA) for eliminating atrial fibrillation (AF)?

Methods:

The subjects of the FAST (Atrial Fibrillation catheter Ablation Versus Surgical Ablation Treatment) study were 124 patients (mean age 56 years) with drug-refractory AF (persistent in 33%) and left atrial diameter >40 mm or a prior failed ablation procedure. The patients were randomly assigned to RFCA (n = 63) or SA (n = 61). RFCA consisted of wide-area pulmonary vein isolation (PVI) and optional supplemental ablation lines. SA consisted of PVI using a bipolar RF ablation clamp, epicardial ganglia ablation, left atrial appendage excision, and optional ablation lines. Efficacy was assessed with serial 7-day Holter monitors. The primary efficacy endpoint was freedom from AF/flutter/tachycardia lasting >30 seconds off antiarrhythmic drug therapy at 12 months.

Results:

The primary efficacy endpoint was achieved significantly more often by SA (65.6%) than by RFCA (36.5%). The procedure-related complication rate also was significantly higher with SA (23%) than with RFCA (3.2%). The prevalence of significant adverse events during 12-month follow-up was similar in both groups (11.5-12.7%).

Conclusions:

In patients with AF and an enlarged left atrium or prior unsuccessful catheter ablation, SA is more efficacious than RFCA, but associated with a several-fold higher risk of procedure-related complications.

Perspective:

The study is notable because it is the first randomized comparison of SA versus RFCA for AF in patients with an enlarged left atrium or prior failed ablation procedure. A limitation of the study is that the ablation strategy in both treatment groups was different at the two centers. However, the efficacy rates were similar at both centers, indicating that a non-uniform ablation strategy did not affect the results.

Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: Ganglia, Follow-Up Studies, Heart Atria, Pulmonary Veins, Electrocardiography, Tachycardia, Prevalence, Atrial Appendage, Cardiomyopathies, Catheter Ablation, Atrial Flutter


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