Progression of atrial fibrillation after cryoablation or drug therapy
Atrial fibrillation is a chronic, progressive disorder, and persistent forms of atrial fibrillation are associated with an increased risk of thromboembolism and heart failure. Catheter ablation as an initial therapy can modify the pathogenic mechanism of atrial fibrillation and change the progression to persistent atrial fibrillation.
We report a 3-year follow-up of patients with paroxysmal, untreated atrial fibrillation who were enrolled in a trial in which they were randomly assigned to undergo initial rhythm control therapy with cryoballoon ablation or to receive antiarrhythmic drug therapy. All patients had implanted loop recorders installed at the time of study entry, and evaluation was performed through downloaded daily recordings and personal visits every 6 months. Data related to a first episode of persistent atrial fibrillation (lasting ≥7 days or lasting 48 hours to 7 days but requiring cardioversion for termination), recurrent atrial tachyarrhythmia (defined as atrial fibrillation, flutter, or tachycardia lasting ≥30 seconds), burden Atrial fibrillation (percentage of time in atrial fibrillation), quality of life metrics, health care utilization, and safety were collected.
A total of 303 patients were included, of which 154 patients underwent initial therapy for rhythm control with cryoballoon ablation, and 149 were assigned to therapy with antiarrhythmic drugs. During 36 months of follow-up, 3 patients (1.9%) in the ablation group had an episode of persistent atrial fibrillation, compared with 11 patients (7.4%) in the antiarrhythmic drug group (hazard ratio, 0, 25; 95% confidence interval [CI], 0.09 to 0.70). Recurrent atrial tachyarrhythmia occurred in 87 patients in the ablation group (56.5%) and in 115 in the antiarrhythmic group (77.2%) (hazard ratio, 0.51; 95% CI, 0.38 to 0.67) . The median percentage of atrial fibrillation time was 0.00% (interquartile range, 0.00 to 0.12) in the ablation group and 0.24% (interquartile range, 0.01 to 0.94) in the antiarrhythmic drug group . After 3 years, 8 patients (5.2%) in the ablation group and 25 (16.8%) in the antiarrhythmic group were hospitalized (relative risk, 0.31; 95% CI, 0.14 to 0.66). Serious adverse events occurred in 7 patients (4.5%) in the ablation group and in 15 (10.1%) in the antiarrhythmic group.
Initial treatment of paroxysmal atrial fibrillation with catheter-based cryoballoon ablation was associated with a lower incidence of persistent atrial fibrillation or recurrent atrial tachyarrhythmia during 3-year follow-up compared with initial use of antiarrhythmic drugs. (Funded by the Canadian Cardiac Arrhythmia Network and others; number EARLY-AF ClinicalTrials.gov, NCT02825979.)
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