Comparing the effectiveness of different catheter ablation technologies to help Atrial Fibrillation (AF) patients live ‘disease free’, Prof. Dhiraj Gupta, consultant cardiologist and electrophysiologist at Liverpool Heart and Chest Hospital, (Liverpool, UK).
The number of AF patients in Europe is at a record high, with approximately 11 million patients currently living with AF.1 Many AF patients seek medical care to find relief from uncomfortable symptoms such as fatigue, dizziness, anxiety and shortness of breath, and to prevent further serious conditions such as AF-related stroke2, which continues to affect many people in spite of increased uptake of newer oral anticoagulants. As hospitals and clinics resume procedures that were delayed due to COVID-19, it is time to examine what treatment options we should be recommending for our AF patients.
Ablation is an important, yet underused, treatment option
With a variety of treatment options available, it is important that we understand the comparative effectiveness of each option to ensure patients receive the treatment that provides them with the greatest chance of stopping disease progression and living ‘disease free’. Catheter ablation is proven to be more effective in delaying disease progression than AADs (anti-arrhythmic drugs) and doubles the improvement in patients’ quality of life when compared with patients being treated with AAD alone.3,4
However, access to ablation is limited – only about 4% of eligible patients in EMEA receive catheter ablation treatment.5 If we would like to improve long-term outcomes for patients with AF, this situation needs to improve.
The value of technology
While we have made significant progress in treating AF, we must continue to seek and adopt innovative technologies and techniques that allow us to further improve outcomes for patients and ease the growing burden that the disease is placing on healthcare systems. Two recent studies published in the Journal of Comparative Effectiveness and Advances in Therapy compared different ablation technologies to help guide patients and physicians in their decision making. The Network Meta-Analysis (NMA) and Matching Adjusted Indirect Comparison (MAIC) studies allowed us to indirectly compare different treatment options, including the latest, most innovative ablation catheter technology.6,7
Network Meta-Analysis (NMA)
The NMA evaluated five different ablation catheter devices. The latest RF ablation technology, THERMOCOOL SMARTTOUCH® (ST) and THERMOCOOL SMARTTOUCH® SF Catheters (STSF) with CARTO VISITAG™ with SURPOINT™(Ablation Index) demonstrated superior effectiveness compared to other currently available ablation devices in achieving 12-month freedom from atrial arrhythmias in paroxysmal AF patients. ST/STSF with SURPOINT™ (Ablation Index) was ranked first among treatments and had the highest probability of being the best treatment (i.e. Surface Under the Cumulative Ranking curve Area), at 99.2%.6
Matching-Adjusted Indirect Comparison (MAIC) study
This MAIC looked at the 12-month effectiveness of ST/STSF with SURPOINT™ (Ablation Index) compared to second generation cryoballoon (CB) ablation in patients with paroxysmal AF. The study allowed for indirect comparison of the two treatments, using individual patient-level data (IPD) from one study and reported data from other studies to facilitate robust matching and simulate a randomized trial. After matching and adjusting, ST/STSF with SURPOINT ™ (Ablation Index) was associated with a 70% reduction in 12-month arrhythmia recurrence in comparison to CB when adjusted for age, left ventricular ejection fraction and sex.7
The best option for ablation patients
With progressive innovation enhancing catheter ablation technologies, we must also explore ways to improve procedural efficiencies, reduce patient recovery time and reduce the financial burden of AF.
The recent multicentre VISTAX study adds additional support to the value of ST/STSF with SURPOINT™ (Ablation Index) demonstrating that nearly four out of five study participants achieved freedom from atrial fibrillation at 12 months in spite of extremely intensive ECG monitoring.8 When assessed on clinical-standard of care monitoring, the success rates were even higher, at nine out of ten. Further research in this area could create value for healthcare systems and patients. At present, it is critical that healthcare professionals (HCPs) including primary care physicians, cardiologists and emergency medical specialists, as well as patients, are educated on the burden of AF and the available treatment options and their relative effectiveness.
Links to the full studies are available below
**The findings and conclusions expressed in this article are those reached independently by the author. Professor Gupta has not been compensated for writing this article.
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1. Zoni-Berisso M, Lercari F, Carazza T, Domenicucci S (2014) Epidemiology of atrial fibrillation: European perspective. Clin Epidemiol 6 213-220.
2. What are the Symptoms of Atrial Fibrillation? 2016. https://www.heart.org/en/health-topics/atrial-fibrillation/what-are-the-symptoms-of-atrial-fibrillation-afib-or-af. Accessed September 8, 2020
3. Mark DB, Anstrom KJ, Sheng S, Piccini JP, Baloch KN et al. (2019) Effect of Catheter Ablation vs Medical Therapy on Quality of Life Among Patients With Atrial Fibrillation: The CABANA Randomized Clinical Trial. JAMA
4. Jais P, Cauchemez B, Macle L, Daoud E, Khairy P et al. (2008) Catheter ablation versus antiarrhythmic drugs for atrial fibrillation: the A4 study. Circulation 118 (24): 2498-2505
5. Pillarisetti J, Lakkireddy D. Atrial fibrillation in Europe: state of the state in disease management! Bloch Heart Rhythm Center, Division of Cardiovascular Diseases, Cardiovascular Research Institute, University of Kansas Hospital & Medical Center, Kansas City, KS. European Heart Journal (2014) 35, 3326–3327
6. Dhiraj Gupta et al. Comparative Effectiveness of Catheter Ablation Devices in the Treatment of Atrial Fibrillation: A Network Meta-analysis of Patients in Prospective Studies. Journal of Comparative Effectiveness Research. (2020) PMID:31913063 DOI:10.2217/cer-2019-0165
7. Ahmed Hussein, Dhiraj Gupta et al. Treatment of Atrial Fibrillation Using Ablation Index-Guided Contact Force Ablation: A Matching-Adjusted. Indirect Comparison to Cryoballoon Ablation. Advances in Therapy (2019) PMID:31865547 DOI: 10.1007/s12325-019-01173-4
8. Mattias Duytschaever et al. Standardized pulmonary vein isolation workflow to enclose veins with contiguous lesions: the multicentre VISTAX trial. European Society of Cardiology. (2020) doi:10.1093/europace/euaa157
For healthcare professionals in EMEA.
Important information: Prior to use, refer to the instructions for use supplied with this device for indications, contraindications, side effects, warnings and precautions. The CARTO VISITAG™ Module provides access to data collected during the application of RF energy. The data does not indicate the effectiveness of RF energy application.
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