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Updated: May 5, 2026
Catheter Ablation in Combination With Left Atrial Appendage Closure for Atrial Fibrillation
Published on: February 26, 2013
Catheter ablation vs. thoracoscopic surgical ablation in long-standing persistent atrial fibrillation: CASA-AF
Shouvik Haldar1,2, Habib Rehman Khan2,3, Vennela Boyalla1,2
1Royal Brompton & Harefield NHS Foundation Trust, Sydney Street, London SW3 6NP, UK.
Insights
Thoracoscopic surgical ablation (SA) is not superior to catheter ablation (CA) for treating long-standing persistent atrial fibrillation (LSPAF). CA offered better symptom improvement and quality of life, despite similar efficacy rates in this study.
Area of Science:
- Cardiology
- Interventional Electrophysiology
- Surgical Innovation
Background:
- Long-standing persistent atrial fibrillation (LSPAF) presents treatment challenges with suboptimal outcomes from catheter ablation (CA).
- Thoracoscopic surgical ablation (SA) has emerged as a potentially effective alternative for atrial fibrillation (AF).
Purpose of the Study:
- To compare the efficacy and safety of thoracoscopic surgical ablation (SA) versus catheter ablation (CA) as a first-line interventional strategy for de novo long-standing persistent atrial fibrillation (LSPAF).
Main Methods:
- A multicentre randomized controlled trial involving 120 LSPAF patients randomized to SA or CA.
- Primary outcome: freedom from AF/atrial tachycardia (AT) without anti-arrhythmic drugs at 12 months.
- Secondary outcomes: clinical success, adverse events, symptom changes, quality-of-life scores, and cost-effectiveness.
Main Results:
- No significant difference in freedom from AF/AT between SA (26%) and CA (28%) at 12 months (P=0.83).
- Clinical success rates (≥75% AF/AT burden reduction) were similar: 67% for SA vs. 77% for CA (P=0.3).
- SA was associated with higher costs and fewer quality-adjusted life-years (QALYs) compared to CA (0.78 vs. 0.85, P=0.02).
Conclusions:
- Single-procedure thoracoscopic SA is not superior to catheter ablation for treating LSPAF.
- Catheter ablation demonstrated superior improvements in patient symptoms and quality-adjusted life-years during the 12-month follow-up.
Aims:
Long-standing persistent atrial fibrillation (LSPAF) is challenging to treat with suboptimal catheter ablation (CA) outcomes. Thoracoscopic surgical ablation (SA) has shown promising efficacy in atrial fibrillation (AF). This multicentre randomized controlled trial tested whether SA was superior to CA as the first interventional strategy in de novo LSPAF.
Methods And Results:
We randomized 120 LSPAF patients to SA or CA. All patients underwent predetermined lesion sets and implantable loop recorder insertion. Primary outcome was single procedure freedom from AF/atrial tachycardia (AT) ≥30 s without anti-arrhythmic drugs at 12 months. Secondary outcomes included clinical success (≥75% reduction in AF/AT burden); procedure-related serious adverse events; changes in patients' symptoms and quality-of-life scores; and cost-effectiveness. At 12 months, freedom from AF/AT was recorded in 26% (14/54) of patients in SA vs. 28% (17/60) in the CA group [OR 1.128, 95% CI (0.46-2.83), P = 0.83]. Reduction in AF/AT burden ≥75% was recorded in 67% (36/54) vs. 77% (46/60) [OR 1.13, 95% CI (0.67-4.08), P = 0.3] in SA and CA groups, respectively. Procedure-related serious adverse events within 30 days of intervention were reported in 15% (8/55) of patients in SA vs. 10% (6/60) in CA, P = 0.46. One death was reported after SA. Improvements in AF symptoms were greater following CA. Over 12 months, SA was more expensive and provided fewer quality-adjusted life-years (QALYs) compared with CA (0.78 vs. 0.85, P = 0.02).
Conclusion:
Single procedure thoracoscopic SA is not superior to CA in treating LSPAF. Catheter ablation provided greater improvements in symptoms and accrued significantly more QALYs during follow-up than SA.
Clinical Trial Registration:
ISRCTN18250790 and ClinicalTrials.gov: NCT02755688.
