Practice Update: Cardiology

ATRIAL FIBRILLATION

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JOURNAL SCAN Effect of left atrial appendage excision on procedure outcome in patients with persistent atrial fibrillation undergoing surgical ablation Heart Rhythm Take-home message approaches for PersAF via video-assist- ed thoracoscopic: PVI + box lesion and PVI + box lesion + LAA excision.

JOURNAL SCAN Current interventions effective for stroke prevention in atrial fibrillation Journal of the American Heart Association Take-home message • The authors of this study performed a meta-analysis of 21 randomised clini- cal trials that included 96,017 patients with nonvalvular atrial fibrillation (AF). They evaluated efficacy of novel oral anticoagulants (NOACs; apixaban, da- bigatran, edoxaban, and rivaroxaban), vitamin K antagonists, aspirin, and the Watchman device in reducing the combination of stroke and systemic embolism (primary outcome) and all- causemortality (secondary outcome). They also evaluated these interven- tions for safety using combined rates of major extracranial bleeding and intracranial haemorrhage. All treat- ments were found to reduce risk of stroke and systemic embolism signifi- cantly and all-cause mortality in pa- tients with nonvalvular AF compared with placebo. Apixaban, dabigatran, and edoxaban were also found to significantly reduce risk of all-cause death when compared with vitamin K antagonists. • All currently accepted treatments for nonvalvular AF result in significant re- duction in stroke/systemic embolism and all-cause mortality, although the efficacy differs between drug classes. BACKGROUND The goal of this study was to compare the safety and ef- fectiveness of individual antiembolic interventions in nonvalvular atrial fibrillation (AF): novel oral anticoagu- lants (NOACs) (apixaban, dabigatran, edoxaban, and rivaroxaban); vitamin K antagonists (VKA); aspirin; and the Watchman device. METHODS AND RESULTS A network meta-analysis of randomised, clinical trials (RCTs) was performed. RCTs that included patients with prosthetic cardiac valves or mitral stenosis, mean or median follow-up <6 months, <200 participants, without published report in English language, and NOAC phase II studies were excluded. The placebo/control arm received either placebo or no treatment. The primary efficacy outcome was the combination of stroke (of any type) and systemic embolism. All-cause mortality served as a secondary efficacy outcome. The primary safety outcome was the com- bination of major extracranial bleeding and intracranial hemorrhage. A total of 21 RCTs (96 017 nonvalvular AF patients; median age, 72 years; 65% males; median follow-up, 1.7 years) were included. In comparison to placebo/control, use of aspirin (odds ratio [OR], 0.75 [95% CI, 0.60–0.95]), VKA (0.38 [0.29–0.49]), apixaban (0.31 [0.22–0.45]), dabigatran (0.29 [0.20– 0.43]), edoxaban (0.38 [0.26–0.54]), rivaroxaban (0.27 [0.18–0.42]), and the Watchman device (0.36 [0.16–0.80]) significantly reduced the risk of any stroke or systemic embolism in nonval- vular AF patients, as well as all-cause mortality (aspirin: OR, 0.82 [0.68–0.99]; VKA: 0.69 [0.57–0.85]; apixaban: 0.62 [0.50–0.78]; dabigatran: 0.62 [0.50– 0.78]; edoxaban: 0.62 [0.50–0.77]; rivaroxaban: 0.58 [0.44–0.77]; and the Watchman device: 0.47 [0.25–0.88]). Apixaban (0.89 [0.80–0.99]), dabi- gatran (0.90 [0.82–0.99]), and edoxa- ban (0.89 [0.82–0.96]) reduced risk of all-cause death as compared to VKA. CONCLUSIONS The entire spectrum of therapy to prevent thromboembolism in nonvalvular AF significantly reduced stroke/systemic embolism events and mortality. Comparative effectiveness of interventions for stroke preven- tion in atrial fibrillation: a network meta-analysis J Am Heart Assoc 2016;5:e003206, LG Tereshchenko, CA Henrikson, J Cigarroa, JS Steinberg

lesion + LAA excision after a single abla- tion procedure without AAD (P = 0.73). Freedom from any atrial arrhythmia after single procedure with or without AAD was also nonsignificant: 70.9% vs 74.7%, respectively. There were no significant differences in adverse events between groups, including death, transient is- chaemic attack, stroke, pneumothorax and hydrothorax. CONCLUSIONS Among patients with persAF, we found no reduction in the rate of recurrent AF when LAA excision was performed in addition to PVI and box lesion during surgical ablation. Effect of left atrial appendage excision on procedure outcome in patients with persistent atrial fibrillation undergoing surgical ablation Heart Rhythm 2016; [EPub Ahead of Print], A Romanov, E Pokushalov, D Elesin, et al.

• The authors randomly assigned 176 patients with persistent atrial fibrillation to two surgical groups to evaluate the efficacy of LAA excision with an 18-month follow-up. The two groups were pulmonary vein isolation (PVI) + box lesion vs PVI + box lesion + LAA excision. There were no significant differences in freedom from atrial fibrillation with or without antiarrhythmic medication and no significant differences in adverse events between the two groups. • No improvement in atrial fibrillation or decrease in adverse events was found with adding LAA to PVI and box lesion surgical intervention for persistent atrial fibrillation.

METHODS We randomly assigned 176 patients with PersAF to video-assisted thoracoscopic surgical ablation with PVI + box lesion (88 patients) or PVI + box lesion + LAA excision (88 patients). The primary endpoint was freedom from any documented atrial arrhythmia lasting longer than 30 seconds after a single ablation procedure without antiarrhyth- mic drug (AAD). RESULTS After 18 months of follow-up, 61 (70.9%) out of 86 patients assigned to PVI + box lesion were free from recur- rent AF, as compared with 64 (73.6%) out of 87 patients assigned to PVI + box

addition to pulmonary vein isolation (PVI) is required to maximise benefits for PersAF after ablation. OBJECTIVE To compare the efficacy and safety of two surgical ablation

BACKGROUND Catheter ablation is less successful for persistent atrial fibrilla- tion (PersAF) than for paroxysmal atrial fibrillation. Some studies suggest that left atrial appendage (LAA) isolation in

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