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AFACT: Patients with advanced AF do not benefit from ganglionic plexus ablation

SAN FRANCISCO — Additional ganglionic plexus ablation during thoracoscopic surgery does not provide improved rhythm outcomes and may cause complications in patients with advanced atrial fibrillation, researchers reported at the Heart Rhythm Society Annual Scientific Sessions.

Joris R. de Groot, MD, PhD, cardiologist at Academic Medical Center, Amsterdam, the Netherlands, explained during a Late Breaking Clinical Trial presentation that “patients with advanced AF present a challenge for ablation, and pulmonary vein isolation is usually not sufficient to treat those patients.”

However, performance of ganglionic plexus ablation was associated with excess periprocedural major bleeding, sinus node dysfunction and pacemaker implantations.

In the AFACT trial, the researchers randomly assigned 240 patients (mean age, 60 years, 73% men; 59% with persistent AF) to either ganglionic plexus ablation (n = 117) or no ablation (n = 123) after undergoing pulmonary vein isolation or pulmonary vein isolation plus a roof and trigone line. The average AF duration was 5 to 6 years.

Procedure time with ablation was 185 minutes with ablation and 168 minutes without it (P = .015). Follow-up with ECG and 24-hour Holter monitoring occurred every 3 months for 1 year.

According to the results, the addition of ganglionic plexus ablation led to a 100% elimination of high frequency stimulation induced evoked vagal responses compared with 87% residual vagal activity in the control group, supporting selective ablation of the ganglionic plexus. By the end of follow-up, four patients from the ganglionic plexus ablation group had died vs. none in the control group, but no deaths were procedure-related (P = .055).

There was no difference in freedom from AF recurrence in patients treated with ganglionic plexus ablation or those treated without it (patients with paroxysmal AF: ablation group, 80%; control group, 74.5%; P = .6; patients with persistent AF: ablation group, 65.7%; control group, 62.9%; P = .9).

Nine major bleeding events, one requiring a sternotomy, occurred in the ablation group compared with none in the control group (P < .001). Sinus node dysfunction occurred in 12 who received ganglionic plexus ablatio[JdG1] n and four controls (P = .038). In addition, six pacemaker implantations occurred in the  ganglionic plexus ablation group (5%; P = .013).

“Thoracoscopic ablation of ganglionic plexus confers no benefit in this study and no benefit in any of the subanalyses, however, ganglionic plexus ablation is significantly associated with more major adverse events. We conclude that ganglionic plexus ablation should not be performed in patients with AF,” de Groot said. – by Tracey Romero

Reference:

de Groot J, et al. LBCT01. Presented at: Heart Rhythm Society Annual Scientific Sessions; May 4-7, 2016; San Francisco.

Disclosure: Cardiology Today was unable to obtain relevant financial disclosures.

SAN FRANCISCO — Additional ganglionic plexus ablation during thoracoscopic surgery does not provide improved rhythm outcomes and may cause complications in patients with advanced atrial fibrillation, researchers reported at the Heart Rhythm Society Annual Scientific Sessions.

Joris R. de Groot, MD, PhD, cardiologist at Academic Medical Center, Amsterdam, the Netherlands, explained during a Late Breaking Clinical Trial presentation that “patients with advanced AF present a challenge for ablation, and pulmonary vein isolation is usually not sufficient to treat those patients.”

However, performance of ganglionic plexus ablation was associated with excess periprocedural major bleeding, sinus node dysfunction and pacemaker implantations.

In the AFACT trial, the researchers randomly assigned 240 patients (mean age, 60 years, 73% men; 59% with persistent AF) to either ganglionic plexus ablation (n = 117) or no ablation (n = 123) after undergoing pulmonary vein isolation or pulmonary vein isolation plus a roof and trigone line. The average AF duration was 5 to 6 years.

Procedure time with ablation was 185 minutes with ablation and 168 minutes without it (P = .015). Follow-up with ECG and 24-hour Holter monitoring occurred every 3 months for 1 year.

According to the results, the addition of ganglionic plexus ablation led to a 100% elimination of high frequency stimulation induced evoked vagal responses compared with 87% residual vagal activity in the control group, supporting selective ablation of the ganglionic plexus. By the end of follow-up, four patients from the ganglionic plexus ablation group had died vs. none in the control group, but no deaths were procedure-related (P = .055).

There was no difference in freedom from AF recurrence in patients treated with ganglionic plexus ablation or those treated without it (patients with paroxysmal AF: ablation group, 80%; control group, 74.5%; P = .6; patients with persistent AF: ablation group, 65.7%; control group, 62.9%; P = .9).

Nine major bleeding events, one requiring a sternotomy, occurred in the ablation group compared with none in the control group (P < .001). Sinus node dysfunction occurred in 12 who received ganglionic plexus ablatio[JdG1] n and four controls (P = .038). In addition, six pacemaker implantations occurred in the  ganglionic plexus ablation group (5%; P = .013).

“Thoracoscopic ablation of ganglionic plexus confers no benefit in this study and no benefit in any of the subanalyses, however, ganglionic plexus ablation is significantly associated with more major adverse events. We conclude that ganglionic plexus ablation should not be performed in patients with AF,” de Groot said. – by Tracey Romero

Reference:

de Groot J, et al. LBCT01. Presented at: Heart Rhythm Society Annual Scientific Sessions; May 4-7, 2016; San Francisco.

Disclosure: Cardiology Today was unable to obtain relevant financial disclosures.

    Perspective
    Daniel J. Cantillon

    Daniel J. Cantillon

    AFACT is a straightforward, well-conducted study that showed that ganglionic plexus ablation not only lacks benefit, but also carries a significant amount of harm. The authors quite appropriately recommended that it not be routinely performed. However, this does not necessarily portend the end of neural-based modulatory treatment for AF, but  this field does need to find a new direction.

    • Daniel J. Cantillon, MD, FACC, FHRS
    • Staff physician, Section of Cardiac Electrophysiology and Pacing Medical Director, Central Monitoring Unit Associate Professor of Medicine Cleveland Clinic

    Disclosures: Cantillon reports no relevant financial disclosures.

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