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Randomized Controlled Trial
. 2023 Jan 10;329(2):127-135.
doi: 10.1001/jama.2022.23722.

Effect of Catheter Ablation Using Pulmonary Vein Isolation With vs Without Posterior Left Atrial Wall Isolation on Atrial Arrhythmia Recurrence in Patients With Persistent Atrial Fibrillation: The CAPLA Randomized Clinical Trial

Peter M Kistler  1   2   3   4   5   6 , David Chieng  1   2   3   4 , Hariharan Sugumar  1   2   3   4 , Liang-Han Ling  1   2   3   4 , Louise Segan  1   2   3   4 , Sonia Azzopardi  1   2 , Ahmed Al-Kaisey  3   7 , Ramanathan Parameswaran  3   7 , Robert D Anderson  3   7 , Joshua Hawson  3   7 , Sandeep Prabhu  1   2   3   8 , Aleksandr Voskoboinik  1   2   3   4 , Geoffrey Wong  3   7 , Joseph B Morton  3   7 , Bhupesh Pathik  3   7 , Alex J McLellan  3   7   9 , Geoffrey Lee  3   7 , Michael Wong  3   7   10 , Sue Finch  3 , Rajeev K Pathak  11   12 , Deep Chandh Raja  11   12 , Laurence Sterns  13 , Matthew Ginks  14 , Christopher M Reid  5   15 , Prashanthan Sanders  16 , Jonathan M Kalman  3   5   7
Affiliations
Randomized Controlled Trial

Effect of Catheter Ablation Using Pulmonary Vein Isolation With vs Without Posterior Left Atrial Wall Isolation on Atrial Arrhythmia Recurrence in Patients With Persistent Atrial Fibrillation: The CAPLA Randomized Clinical Trial

Peter M Kistler et al. JAMA. .

Abstract

Importance: Pulmonary vein isolation (PVI) alone is less effective in patients with persistent atrial fibrillation (AF) compared with paroxysmal AF. The left atrial posterior wall may contribute to maintenance of persistent AF, and posterior wall isolation (PWI) is a common PVI adjunct. However, PWI has not been subjected to randomized comparison.

Objective: To compare PVI with PWI vs PVI alone in patients with persistent AF undergoing first-time catheter ablation.

Design, setting, and participants: Investigator initiated, multicenter, randomized clinical trial involving 11 centers in 3 countries (Australia, Canada, UK). Symptomatic patients with persistent AF were randomized 1:1 to either PVI with PWI or PVI alone. Patients were enrolled July 2018-March 2021, with 1-year follow-up completed March 2022.

Interventions: The PVI with PWI group (n = 170) underwent wide antral pulmonary vein isolation followed by posterior wall isolation involving linear ablation at the roof and floor to achieve electrical isolation. The PVI-alone group (n = 168) underwent wide antral pulmonary vein isolation alone.

Main outcomes and measures: Primary end point was freedom from any documented atrial arrhythmia of more than 30 seconds without antiarrhythmic medication at 12 months, after a single ablation procedure. The 23 secondary outcomes included freedom from atrial arrhythmia with/without antiarrhythmic medication after multiple procedures, freedom from symptomatic AF with/without antiarrhythmic medication after multiple procedures, AF burden between study groups at 12 months, procedural outcomes, and complications.

Results: Among 338 patients randomized (median age, 65.6 [IQR, 13.1] years; 76.9% men), 330 (97.6%) completed the study. After 12 months, 89 patients (52.4%) assigned to PVI with PWI were free from recurrent atrial arrhythmia without antiarrhythmic medication after a single procedure, compared with 90 (53.6%) assigned to PVI alone (between-group difference, -1.2%; hazard ratio [HR], 0.99 [95% CI, 0.73-1.36]; P = .98). Of the secondary end points, 9 showed no significant difference, including freedom from atrial arrhythmia with/without antiarrhythmic medication after multiple procedures (58.2% for PVI with PWI vs 60.1% for PVI alone; HR, 1.10 [95% CI, 0.79-1.55]; P = .57), freedom from symptomatic AF with/without antiarrhythmic medication after multiple procedures (68.2% vs 72%; HR, 1.20 [95% CI, 0.80-1.78]; P = .36) or AF burden (0% [IQR, 0%-2.3%] vs 0% [IQR, 0%-2.8%], P = .47). Mean procedural times (142 [SD, 69] vs 121 [SD, 57] minutes, P < .001) and ablation times (34 [SD, 21] vs 28 [SD, 12] minutes, P < .001) were significantly shorter for PVI alone. There were 6 complications for PVI with PWI and 4 for PVI alone.

Conclusions and relevance: In patients undergoing first-time catheter ablation for persistent AF, the addition of PWI to PVI alone did not significantly improve freedom from atrial arrhythmia at 12 months compared with PVI alone. These findings do not support the empirical inclusion of PWI for ablation of persistent AF.

Trial registration: anzctr.org.au Identifier: ACTRN12616001436460.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Kistler reported receiving grants from Baker Department of Metabolic Health University of Melbourne; receiving speaker fees from Abbott Medical; and serving on an advisory board for Biosense Webster. Dr Ling reported receiving grants from Abbott Australia. Dr Al-Kaisey reported receiving grants from the National Health and Medical Research Council (NHMRC) and National Heart Foundation of Australia. Dr Prabhu reported receiving grants from NHMRC, University of Melbourne, and Baker Heart and Diabetes Institute; receiving postdoctoral fellowship support from the Heart Foundation; receiving advisory fees from Biosense Webster; and receiving speaker fees from Abbott Medical. Dr G. Wong reported receiving grants from the National Heart Foundation. Dr Sterns reported receiving personal fees from Biosense Webster. Dr Ginks reported serving on speaker bureaus for Biosense Webster Speaker and Abbott. Dr Sanders reported serving on advisory boards for Medtronic, Abbott Medical, CathRx, Pacemate, and Boston Scientific and reported being supported by a practitioner fellowship from NHMRC and by the National Heart Foundation of Australia. Dr Kalman reported receiving fellowship support from Medtronic and Biosense Webster. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Pulmonary Vein Isolation With and Without Posterior Wall Isolation
A, Pulmonary vein isolation (PVI) with posterior wall isolation achieved by adding a roof ablation line connecting the superior aspects of the pulmonary veins and floor ablation line connecting the inferior aspects of the pulmonary veins. B, Wide antral circumferential ablation around the pulmonary veins bilaterally to achieve PVI.
Figure 2.
Figure 2.. Recruitment, Randomization, and Patient Flow in the CAPLA Trial
AF indicates atrial fibrillation; CAPLA, Catheter Ablation for Persistent Atrial Fibrillation: A Multicentre Randomized Trial of Pulmonary Vein Isolation vs PVI With Posterior Left Atrial Wall Isolation; PVI, pulmonary vein isolation; PWI, posterior wall isolation.
Figure 3.
Figure 3.. Any Atrial Arrhythmia Recurrence, Without Antiarrhythmic Medication, After a Single Ablation Procedure
There was no significant difference in any atrial arrhythmia recurrence, after 90 days’ blanking period, without antiarrhythmic medication from a single procedure, between PVI alone vs PVI with PWI. Median observation time was 275 days in both groups.
See this image and copyright information in PMC

Comment in

References

    1. Calkins H, Hindricks G, Cappato R, et al. . 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm. 2017;14(10):e275-e444. doi:10.1016/j.hrthm.2017.05.012 - DOI - PMC - PubMed
    1. Kalman JM, Sanders P, Rosso R, Calkins H. Should we perform catheter ablation for asymptomatic atrial fibrillation? Circulation. 2017;136(5):490-499. doi:10.1161/CIRCULATIONAHA.116.024926 - DOI - PubMed
    1. Kirchhof P, Benussi S, Kotecha D, et al. . 2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Europace. 2016;18(11):1609-1678. doi:10.1093/europace/euw295 - DOI - PubMed
    1. Kirchhof P, Camm AJ, Goette A, et al. ; EAST-AFNET 4 Trial Investigators . Early rhythm-control therapy in patients with atrial fibrillation. N Engl J Med. 2020;383(14):1305-1316. doi:10.1056/NEJMoa2019422 - DOI - PubMed
    1. Kistler PM, Chieng D. Persistent atrial fibrillation in the setting of pulmonary vein isolation—where to next? J Cardiovasc Electrophysiol. 2020;31(7):1857-1860. doi:10.1111/jce.14298 - DOI - PubMed

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