Results from one of the world’s largest studies of atrial fibrillation (AFib) procedures show that the simple approach is generally best when it comes to ablation, a procedure where doctors destroy or ablate tissue to correct irregular heart rhythms. The findings could change how patients are treated for AFib.
Researchers from Tulane University and partner institutions found that using advanced image-guided technology to more aggressively target diseased areas of the heart that cause arrhythmias did not lead to better patient outcomes – and put some at higher risk of strokes, according to DECAAF II trial results published in JAMA.
“Simplicity is the key. Don’t ablate too much, especially in the later stages,” said study lead author Dr. Nassir Marrouche, director of the Tulane Heart and Vascular Institute and The Research Innovation for Arrhythmia Discoveries (TRIAD) at Tulane University School of Medicine. . “Too much ablation doesn’t help our patients today. It puts them at higher risk. This is a practice-changing finding from our study.”
Atrial fibrillation occurs when the upper and lower chambers of the heart are out of sync, causing the heart to beat irregularly. It affects more than 2.7 million Americans and is a major risk factor for stroke. When atrial fibrillation cannot be controlled with medication, doctors perform a procedure to remove fibrous or diseased areas of the heart with heat or cold to create a scar that disrupts the electrical signal that causes the arrhythmia.
For the study, researchers followed 843 patients with atrial fibrillation undergoing ablation treatment at 44 hospitals in 10 countries, including the United States, Germany, France and Australia. All patients received magnetic resonance imaging (MRI) to quantify the amount of diseased tissue in their heart. (Those with a higher percentage of diseased tissue have a higher risk of arrhythmia relapse, according to results from the original DECAAF trial.)
Half of the patients received standard care – pulmonary vein isolation (PVI) treatment where doctors remove areas in the upper left chamber of the heart where the four pulmonary veins meet.
For the other group, the doctors used the MRI scans to create a detailed 3D map of all the diseased areas along the left atrium of the heart. They performed conventional PVI treatment, then used the digital map to remove diseased tissue more aggressively and precisely outside of conventional treatment areas.
All patients in the study were given smartphone ECG devices to monitor their heart rhythms daily after treatment, and the researchers followed them up at 3, 6 and 12 month intervals.
The researchers found no significant difference in arrhythmia recurrence between the two groups. However, the group that received the more aggressive treatment experienced a higher rate of poor safety outcomes with six patients (1.5%) experiencing a stroke.
Marrouche said the study shows that AFib patients with extensive fibrosis have too much scarring for aggressive ablative therapy to be effective using conventional tools. The researchers also suspect that it was not just the extent of fibrosis that played a role in the study results. By evaluating hundreds of procedures by the world’s leading electrophysiologists, they found that there is little uniformity in how doctors perform ablation procedures, which can also contribute to disparate outcomes, a said Marrouche.
“Atrial fibrillation procedures have become too complex over the years. We ablate hundreds of thousands of people a year now, and we are working to do more and more ablation for the population with fibrillation. persistent or continuous auricularis,” Marrouche said. “But our study shows that this is not necessary, especially for those with more myopathy. Simple ablations can effectively treat these patients instead of resorting to extensive ablation to treat the fibrotic areas that we have trouble treating. control.”
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