Atrial Fibrillation Ablation and Autonomic Modulation Via Thorascopic Surgery

Conditions

Atrial Fibrillation

Keywords

Atrial Fibrillation, Totally Thoracoscopic PV isolation

Brief summary

This study aims at investigating the role of autonomic modulation of AF. Therefore, totally thoracoscopic PV isolation with additional ablation of ganglionated plexi (GP) will be studied against PV isolation alone. Two groups of patients (paroxysmal AF with or without structural heart disease and persistent AF with or without heart disease) of 110 patients each will be studied.

Detailed description

Atrial fibrillation (AF) is the most common chronic arrhythmia in man. Its treatment consists of control of ventricular rate or attempts to restore sinus rhythm. For symptomatic patients who fail on anti arrhythmic drugs, isolation of the pulmonary veins (PV), with additional linear left atrial lesions when appropriate, can cure AF. At least in some, but probably in many patients, the autonomous nervous system plays a pivotal role in the initiation and perpetuation of AF. The autonomic ganglia, or ganglionated plexi (GP) are located within the epicardial fat pads of the left atrium. This study aims at investigating the additional value of ablation of those GPs in addition to totally thoracoscopic PV isolation. Objective of the study: This study aims at investigating the role of autonomic modulation of AF. Therefore, totally thoracoscopic PV isolation with additional ablation of ganglionated plexi (GP) will be studied against PV isolation alone. Two groups of patients (paroxysmal AF with or without structural heart disease and persistent AF with or without heart disease) of 110 patients each will be studied. Study design: This is a single center, randomized single blinded study Study population: Any patient with an indication for non-pharmacological treatment of symptomatic paroxysmal or persistent AF can enter the study. An indication for non-pharmacological treatment exists when patients are symptomatic and have failed on at least one anti-arrhythmic drug. Symptoms of AF include, but are not limited to palpitations, reduced exercise capacity, exertional dyspnea, and fatigue. Failure of anti-arrhythmic therapy is defined as 1) recurrence of AF despite the use of an anti-arrhythmic drug in a clinical efficacious dosing or 2) adverse effects of medication that is not acceptable to the patient. Intervention (if applicable): In patients randomized to additional GP ablation, the following procedures will be carried out during the totally thoracoscopic procedure in addition to the PV isolation (and extended lesion set when appropriate): The left atrial autonomic GPs are localized within the epicardial fat pads and subsequently ablated with radiofrequency current delivered through an ablation probe (AtriCure Isolator™ Transpolar™ pen).

Robin Wesselink, Jolien Neefs, Nicoline W.E. van den Berg, Eva R. Meulendijks, M M Terpstra et al. (11 authors)

BMJ Open2022-03-019 citations

10.1136/bmjopen-2021-056829

Reduced left atrial cardiomyocyte PITX2 and elevated circulating BMP10 predict atrial fibrillation after ablation

Jasmeet S. Reyat, Winnie Chua, Victor Roth Cardoso, Anika Witten, Peter Kastner et al. (16 authors)

JCI Insight2020-08-1988 citations

10.1172/jci.insight.139179

Additional Ganglion Plexus Ablation During Thoracoscopic Surgical Ablation of Advanced Atrial Fibrillation

Wouter R. Berger, Jolien Neefs, Nicoline W.E. van den Berg, Sébastien P.J. Krul, EM Meima-van Praag et al. (10 authors)

JACC. Clinical electrophysiology2018-11-2835 citations

10.1016/j.jacep.2018.10.008

Ganglion Plexus Ablation in Advanced Atrial Fibrillation: The AFACT Study.

Driessen AHG, Berger WR, Krul SPJ, van den Berg NWE, Neefs J, Piersma FR, Chan Pin Yin DRPP, de Jong JSSG, van Boven WP, de Groot JR.

2016-09-01169 citations

10.1016/j.jacc.2016.06.036

22-03: Thoracoscopic Ganglionic Plexus Ablation does not Improve Outcome in Advanced Atrial Fibrillation. The AFACT trial

Joris de Groot, Wouter R. Berger, Sébastien P.J. Krul, Nicoline van den Berg, Jolien Neefs et al. (9 authors)

EP Europace2016-06-011 citations

10.1093/europace/18.suppl_1.i26

Interventions

PROCEDURETotally Thoracoscopic PV isolation

Surgery is performed through three ports bilaterally in the intercostal spaces. PVI is performed with a bipolar radiofrequency clamp and confirmed with a custom made multi-electrode probe with closely spaced (1mm) electrode terminals. Additional left atrial ablation lines are created and conduction block is verified in patients with persistent and permanent AF.

Study design

Allocation

RANDOMIZED

Intervention model

PARALLEL

Primary purpose

TREATMENT

Masking

SINGLE (Subject)

Eligibility

Sex/Gender

ALL

Age

18 Years to 80 Years

Healthy volunteers

No

Inclusion criteria

* Age is between 18 and 80 years * AF is symptomatic, paroxysmal or persistent (hence not long standing persistent) * In case of persistent AF, successful cardioversion within the last 12 months (cardioversion will be considered failed if AF recurs within 48 hours) * AF was documented on ECG, Holter or pacemaker electrogram at least once in the 6 months preceding presentation * At least one class I or III antiarrhythmic drug in standard dosage has failed or is not tolerated * Legally competent and willing and able to sign informed consent * Willing and able to adhere to the follow up visit protocol * Life expectancy of ≥2 years

Exclusion criteria

* Prior catheter ablation for AF within the preceding 4 months * Refusal to take antiarrhythmic medication * Myocardial infarction (defined as CKMB\> twice upper limit of normal) within the preceding 2 months * NYHA class IV/IV heart failure symptoms, or class II-III with a recent decompensation requiring hospitalization or left ventricular ejection fraction\<35% (unless related to or aggravated by AF). * Cerebrovascular accident (defined as any sudden neurological deficit lasting longer than 24 hours, with or without pathological changes on the CT cerebrum) with the preceding 6 months * Known and documented carotid stenosis\>80% * Planned cardiac surgery for other purposes than AF (alone) * Evidence of active infection (as evidenced by increased white blood cell count, elevated CRP level or fever \>38,5 °C) * Unable to undergo TEE * Pregnancy or of childbearing potential without adequate contraception * Requirement of antiarrhythmic medication for ventricular arrhythmias * Presence of intracardiac mass or thrombus (Discovery of any thrombus or intracardiac mass after signing of the informed consent will result in withdrawal of the patient from the study) * Co-morbid condition that possesses undue risk of general anesthesia or port access cardiac surgery (in the opinion of the investigator) * History of previous radiation therapy on the thorax * Circumstances that prevent follow-up (no permanent home or address, transient, etc.)

Design outcomes

Primary

Measure	Time frame	Description
The primary endpoint of the study is freedom of AF after one year after the procedure without the use of antiarrhythmic drugs.	One year	The primary endpoint of the study is freedom of AF after one year after the procedure without the use of antiarrhythmic drugs. Freedom of AF is defined as the absence of documentation of AF on serial Holter recordings during follow up and on ECGs recorded outside the scope of the study. One single episode of \<30 minutes is allowed. Patients complaints about palpitations without the documentation of AF is allowed.

Secondary

Measure	Time frame	Description
Freedom of AF after two years after the procedure without the use of any antiarrhythmic drug	Two Years	Freedom of AF after two years after the procedure without the use of any antiarrhythmic drug. Definition of freedom of AF as above.
Quality of life	One Year	Improvement of functional status as measured by the RAND 36 quality of life questionnaires

Countries

Netherlands

Outcome results

None listed