LAA ligation did not reduce recurrent atrial arrhythmias in persistent AF

Recurrent atrial arrhythmias were not reduced after adjunctive left atrial appendage (LAA) ligation compared with pulmonary vein antral isolation (PVAI) alone in patients with persistent atrial fibrillation (AF) undergoing AF ablation. Patients with early persistent AF and larger LA volumes may benefit more from adjunctive LAA ligation, exploratory analyses revealed. Future studies are needed to verify these exploratory outcomes.

Dr David Wilber (Loyola University Chicago, IL, USA) explained that ablation outcomes via PVAI alone in patients with persistent AF are often suboptimal [1]. Therefore, secondary procedures such as LAA ligation are in development. The prospective, multicentre, randomised aMAZE trial (NCT02513797) aimed to assess the efficacy of LAA ligation with the LARIAT system compared with PVAI in decreasing recurrent atrial arrhythmias. Patients with persistent AF undergoing AF ablation were randomised 2:1 to LAA ligation plus PVAI (n=404) or PVAI alone (n=206). The primary efficacy endpoint was freedom of atrial arrhythmias 12 months after surgery.

The experimental condition did not significantly outperform the control condition: 64.3% of the patients in the LAA ligation plus PVAI condition were free from  12 months after surgery, compared with 59.9% of the patients in the PVAI alone group (see Figure). The Bayesian posterior probability of 0.835 did not meet the superiority criterion (>0.977). Notably, exploratory subgroup analysis revealed that patients with early persistent AF (7 days to 6 months) may benefit relatively more from the LARIAT device than from PVAI alone (7.5% difference in the primary endpoint; P=0.084) compared with patients with late or long-standing persistent AF. In addition, patients with larger LA volumes (≥133 cm^{^3}) show a numerical larger relative benefit of adjunctive LAA ligation (12.4% difference; P=0.093) than patients with smaller LA volumes (<133 cm^{^3}; 2.5% difference).

Figure: Primary endpoint – Freedom of atrial arrhythmias after 1 year [1]



PVAI, pulmonary vein antral isolation.

The percentage of serious adverse events (AEs) 30 days after the LARIAT procedure was 3.4%, meeting the predefined <10% performance goal. Notably, 3 patients in the experimental group experienced serious injuries to cardiac structures, requiring surgery. The 12-month post-surgery LAA ligation closure rates were high, with 100% closure in 84% of the patients.

Although adjunctive LAA ligation with the LARIAT device did not result in significantly reduced atrial arrhythmias in patients with persistent AF undergoing AF ablation, subgroups may benefit from this procedure.

1. 
   
   1. Wilber DJ, et al. Outcomes Of Adjunctive Left Atrial Appendage Ligation Utilizing The LARIAT Compared To Pulmonary Vein Antral Isolation Alone: The aMAZE Trial. LBS03, AHA 2021 Scientific Sessions, 13–15 November.

 

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Posted on 14 January 202214 January 2022