Catheter ablation for persistent atrial fibrillation: A multicenter randomized trial of pulmonary vein isolation (PVI) versus PVI with posterior left atrial wall isolation (PWI) - The CAPLA study

David Chieng; Hariharan Sugumar; Liang-Han Ling; Louise Segan; Sonia Azzopardi; Sandeep Prabhu; Ahmed Al-Kaisey; Aleksandr Voskoboinik; Ramanathan Parameswaran; Joseph B Morton; Bhupesh Pathik; Alex J McLellan; Geoffrey Lee; Michael Wong; Sue Finch; Rajeev K Pathak; Deep Chandh Raja; Prashanthan Sanders; Laurence Sterns; Matthew Ginks; Christopher M Reid; Jonathan M Kalman; Peter M Kistler

doi:10.1016/j.ahj.2021.09.015

Catheter ablation for persistent atrial fibrillation: A multicenter randomized trial of pulmonary vein isolation (PVI) versus PVI with posterior left atrial wall isolation (PWI) - The CAPLA study

Am Heart J. 2022 Jan:243:210-220. doi: 10.1016/j.ahj.2021.09.015. Epub 2021 Oct 4.

Authors

David Chieng¹, Hariharan Sugumar¹, Liang-Han Ling², Louise Segan¹, Sonia Azzopardi³, Sandeep Prabhu⁴, Ahmed Al-Kaisey⁵, Aleksandr Voskoboinik¹, Ramanathan Parameswaran⁵, Joseph B Morton⁵, Bhupesh Pathik⁵, Alex J McLellan⁶, Geoffrey Lee⁵, Michael Wong⁷, Sue Finch⁸, Rajeev K Pathak⁹, Deep Chandh Raja⁹, Prashanthan Sanders¹⁰, Laurence Sterns¹¹, Matthew Ginks¹², Christopher M Reid¹³, Jonathan M Kalman¹⁴, Peter M Kistler¹⁵

Affiliations

¹ The Baker Heart and Diabetes Research Institute, Melbourne, Australia; The Alfred Hospital, Melbourne, Australia,; University of Melbourne, Melbourne, Australia; Cabrini Hospital, Melbourne, Australia.
² The Baker Heart and Diabetes Research Institute, Melbourne, Australia; The Alfred Hospital, Melbourne, Australia,; University of Melbourne, Melbourne, Australia; St Vincent's Private Hospital Fitzroy, Melbourne Australia.
³ The Baker Heart and Diabetes Research Institute, Melbourne, Australia; The Alfred Hospital, Melbourne, Australia.
⁴ The Baker Heart and Diabetes Research Institute, Melbourne, Australia; The Alfred Hospital, Melbourne, Australia,; University of Melbourne, Melbourne, Australia; Mulgrave Private Hospital, Melbourne, Australia.
⁵ University of Melbourne, Melbourne, Australia; Royal Melbourne Hospital, Melbourne, Australia.
⁶ University of Melbourne, Melbourne, Australia; Royal Melbourne Hospital, Melbourne, Australia; St Vincent's Private Hospital Fitzroy, Melbourne Australia.
⁷ University of Melbourne, Melbourne, Australia; Royal Melbourne Hospital, Melbourne, Australia; Epworth Hospital Richmond, Melbourne, Australia.
⁸ University of Melbourne, Melbourne, Australia.
⁹ Canberra Hospital, ACT, Australia; Australian National University, ACT, Australia.
¹⁰ Royal Adelaide Hospital, Adelaide, Australia.
¹¹ Royal Jubilee Hospital, Vancouver Island, British Columbia, Canada.
¹² John Radcliffe Hospital, Oxford, UK.
¹³ Monash University, Melbourne, Australia; Curtin University, Perth, Australia.
¹⁴ University of Melbourne, Melbourne, Australia; Monash University, Melbourne, Australia; Royal Melbourne Hospital, Melbourne, Australia.
¹⁵ The Baker Heart and Diabetes Research Institute, Melbourne, Australia; The Alfred Hospital, Melbourne, Australia,; University of Melbourne, Melbourne, Australia; Cabrini Hospital, Melbourne, Australia; Monash University, Melbourne, Australia; Melbourne Private Hospital, Melbourne, Australia. Electronic address: Peter.kistler@baker.edu.au.

PMID: 34619143
DOI: 10.1016/j.ahj.2021.09.015

Abstract

Background: The success of pulmonary vein isolation (PVI) is reduced in persistent AF (PsAF) compared to paroxysmal AF. Adjunctive ablation strategies have failed to show consistent incremental benefit over PVI alone in randomized studies. The left atrial posterior wall is a potential source of non-PV triggers and atrial substrate which may promote the initiation and maintenance of PsAF. Adding posterior wall isolation (PWI) to PVI had shown conflicting outcomes, with earlier studies confounded by methodological limitations.

Objectives: To determine whether combining PWI with PVI significantly improves freedom from AF recurrence, compared to PVI alone, in patients with PsAF.

Methods: This is a multi-center, prospective, international randomized clinical trial. 338 patients with symptomatic PsAF refractory to anti-arrhythmic therapy (AAD) will be randomized to either PVI alone or PVI with PWI in a 1:1 ratio. PVI involves wide antral circumferential pulmonary vein (PV) isolation, utilizing contact force sensing ablation catheters. PWI involves the creation of a floor line connecting the inferior aspect of the PVs, and a roof line connecting the superior aspect of the PVs. Follow up is for a minimum of 12 months with rhythm monitoring via implantable cardiac device and/or loop monitor, or frequent intermittent monitoring with an ECG device. The primary outcome is freedom from any documented atrial arrhythmia of > 30 seconds off AAD at 12 months, after a single ablation procedure.

Conclusions: This randomized study aims to determine the success and safety of adjunctive PWI to PVI in patients with persistent AF.

Publication types

Multicenter Study
Randomized Controlled Trial

MeSH terms

Atrial Fibrillation* / surgery
Catheter Ablation* / methods
Humans
Prospective Studies
Pulmonary Veins* / surgery
Recurrence
Treatment Outcome