Atrial Fibrillation Catheter Ablation Versus Surgical Ablation Treatment (FAST): A 2-Center Randomized Clinical Trial
Is minimally-invasive surgical ablation (SA) more effective than radiofrequency catheter ablation (RFCA) for eliminating atrial fibrillation (AF)?
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.
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%).
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.
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.
Keywords: Ganglia, Follow-Up Studies, Heart Atria, Pulmonary Veins, Electrocardiography, Tachycardia, Prevalence, Atrial Appendage, Cardiomyopathies, Catheter Ablation, Atrial Flutter
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