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AVATAR-HF: Simplified AF ablation yields good outcomes for less costs

Elvira Manzano
26 Apr 2019

Foregoing intracardiac electrophysiologic mapping was as good as conventional cryoablation with pulmonary vein (PV) mapping in the AVATAR-HF* study, suggesting that a simplified procedure could produce the same outcomes for lower costs. 

Considering that it was a day-case cryoablation, this also means fewer patients with atrial fibrillation (AF) on the waiting lists. On top of that, AF ablation without PV mapping was superior to antiarrhythmic drugs during 1-year follow-up, reported Dr Prapa Kanagaratnam, principal investigator and consultant cardiologist at Imperial College Healthcare NHS Trust, London, UK.

Patients in the AVATAR-AF trial were randomly assigned to AF ablation without PV mapping (AVATAR group, n=110), medical therapy group (anti-arrhythmic group, n=103), or conventional cryoablation using mapping (conventional group, n=108). Mean age of the patients was 60 years, majority of them were male, with CHA2DS2VASC scores largely in the 0–3 range and mean left ventricular ejection fraction of 57–58 percent. [EHRA 2019, abstract LBT1-176]

About 40 percent of patients were taking a class I/III anti-arrhythmic agent, 63–74 percent were on anticoagulants. The AVATAR protocol involved anticoagulation based on guidelines using the CHA2DS2VASC score, sedation or general anaesthesia, transeptal puncture by a catheter, and balloon occlusion of the PV with two 3-minute cryoblations. There was phrenic nerve monitoring using a temporary transvenous pacing wire but there was no specialist electrophysiology catheters or PV isolation assessment done.

Patients who were asymptomatic or had improvement in symptoms were discharged from hospital-based specialist care at 12 weeks and followed at 6, 9, and 12 months. At 1 year, the AVATAR protocol was superior to antiarrhythmic therapy in terms of hospital episodes related to treatment for atrial arrhythmia. There was a significant difference with 23 events in the AVATAR arm vs 76 in the antiarrhythmic arm (p<0.001).

And given the noninferiority of the AVATAR protocol to conventional cryoablation, Kanagaratnam believed it is possible to simplify AF ablation procedures without compromising outcomes. The findings also question two things — the value of drug therapy and whether catheter ablation should be the first-line treatment for AF patients with symptoms, said Kanagaratnam.

Study discussant Dr Jose Merino from the La Paz University Hospital in Madrid, Spain said if mapping can be avoided in future, any catheterization laboratory could do cryoablation. EHRA president and session comoderator Dr Hein Heidbuchel from Antwerp University, Belgium commented that it was “an intriguing and unexpected finding” that the outcomes were similar for the two procedures.

“Interventionists are all struggling to find easier ways to isolate the pulmonary veins. I don’t think AVATAR-AF will be the groundbreaking trial facilitating that …”

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Most Read Articles
Roshini Claire Anthony, 10 Jul 2019

Women who receive a single dose of amoxicillin and clavulanic acid within 6 hours of operative vaginal delivery could significantly reduce their postpartum infection risk, according to the UK-based ANODE* trial.

17 Jun 2019
Podcast: Dr Sara Hurvitz highlights that the addition of ribociclib to endocrine therapy improved overall survival in premenopausal women with HR+, HER2- advanced breast cancer, according to the MONALEESA-7 trial.
Audrey Abella, 05 Jul 2018
The addition of the sodium-glucose cotransporter-2 inhibitor ertugliflozin to metformin improved glycaemic control, body weight, and blood pressure (BP) in patients with inadequately controlled type 2 diabetes (T2D), according to the results of the VERTIS MET* trial presented at ADA 2018.
17 Feb 2019
In patients with type 2 diabetes (T2D), sodium-glucose cotransporter 2 (SGLT2) inhibitor monotherapy, particularly canagliflozin, exerts greater effects on weight compared with metformin and dipeptidyl peptidase 4 (DPP-4) inhibitors or gliptins, according to the results of a meta-analysis.