Augmented Wide Area Circumferential Catheter Ablation for Reduction of Atrial Fibrillation Recurrence - AWARE

Contribution To Literature:

The AWARE trial failed to show that double-wide circumferential ablation prevents recurrent atrial arrhythmias.


The goal of the trial was to evaluate double-wide circumferential ablation compared with single-wide circumferential ablation among patients with paroxysmal atrial fibrillation undergoing catheter ablation.

Study Design

  • Randomization
  • Parallel

Patients with paroxysmal atrial fibrillation were randomized to double-wide circumferential ablation (n = 203) vs. single-wide circumferential ablation (n = 195).

  • Total number of enrollees: 398
  • Duration of follow-up: 12 months
  • Mean patient age: 61 years
  • Percentage female: 33%
  • Percentage with diabetes: 10%

Inclusion criteria:

  • At least 18 years of age
  • Paroxysmal atrial fibrillation (refractory, intolerant, or unwilling to take antiarrhythmic drugs)

Exclusion criteria:

  • Persistent or permanent atrial fibrillation
  • Previous catheter or surgical ablation for atrial fibrillation
  • Presence of known intracardiac thrombus
  • Contraindication to systemic oral anticoagulation therapy
  • Significant valve disease (moderate or severe mitral/aortic stenosis or regurgitation)

Principal Findings:

The primary outcome, recurrent atrial arrhythmia, occurred in 24.6% of the double-wide circumferential ablation group vs. 26.7% of the single-wide circumferential ablation group (p = 0.64).

Secondary outcomes:

  • Repeat catheter ablation: 7.4% of the double-wide circumferential ablation group vs. 10.3% of the single-wide circumferential ablation group
  • Serious adverse events: 6.9% of the double-wide circumferential ablation group vs. 6.7% of the single-wide circumferential ablation group


Among patients with paroxysmal atrial fibrillation, catheter ablation with a double-wide circumferential ablation failed to prevent recurrent atrial arrhythmias compared with a single-wide circumferential ablation. The need for repeat catheter ablation and serious adverse events were similar between treatment groups.


Nair GM, Birnie DH, Nery PB, et al. Standard vs Augmented Ablation of Paroxysmal Atrial Fibrillation for Reduction of Atrial Fibrillation Recurrence: The AWARE Randomized Clinical Trial. JAMA Cardiol 2023;8:475-83.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Prevention, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: Anti-Arrhythmia Agents, Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Catheter Ablation, Recurrence, Secondary Prevention

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