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Radiofrequency Ablation as Initial Therapy in Paroxysmal Atrial Fibrillation
Open accessAbstract
BACKGROUND: There are limited data comparing radiofrequency catheter ablation with antiarrhythmic drug therapy as first-line treatment in patients with paroxysmal atrial fibrillation. METHODS: We randomly assigned 294 patients with paroxysmal atrial fibrillation and no history of antiarrhythmic drug use to an initial treatment strategy of either radiofrequency catheter ablation (146 patients) or therapy with class IC or class III antiarrhythmic agents (148 patients). Follow-up included 7-day Holter-monitor recording at 3, 6, 12, 18, and 24 months. Primary end points were the cumulative and per-visit burden of atrial fibrillation (i.e., percentage of time in atrial fibrillation on Holter-monitor recordings). Analyses were performed on an intention-to-treat basis. RESULTS: There was no significant difference between the ablation and drug-therapy groups in the cumulative burden of atrial fibrillation (90th percentile of arrhythmia burden, 13% and 19%, respectively; P=0.10) or the burden at 3, 6, 12, or 18 months. At 24 months, the burden of atrial fibrillation was significantly lower in the ablation group than in the drug-therapy group (90th percentile, 9% vs. 18%; P=0.007), and more patients in the ablation group were free from any atrial fibrillation (85% vs. 71%, P=0.004) and from symptomatic atrial fibrillation (93% vs. 84%, P=0.01). One death in the ablation group was due to a procedure-related stroke; there were three cases of cardiac tamponade in the ablation group. In the drug-therapy group, 54 patients (36%) underwent supplementary ablation. CONCLUSIONS: In comparing radiofrequency ablation with antiarrhythmic drug therapy as first-line treatment in patients with paroxysmal atrial fibrillation, we found no significant difference between the treatment groups in the cumulative burden of atrial fibrillation over a period of 2 years. (Funded by the Danish Heart Foundation and others; MANTRA-PAF ClinicalTrials.gov number, NCT00133211.).
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In the citing paper
“Catheter ablation or combination therapy is often effective when antiarrhythmic drugs fail.226,[585][586][587]”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [585]
In the citing paper
“AF ablation, when performed in experienced centres by adequately trained teams, is more effective than antiarrhythmic drug therapy in maintaining sinus rhythm, and the complication rate, though not negligible, is similar to the complication rate for antiarrhythmic drugs.585,717,1042”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [585]
In the citing paper
“AF ablation, when performed in experienced centres by adequately trained teams, is more effective than antiarrhythmic drug therapy in maintaining sinus rhythm, and the complication rate, though not negligible, is similar to the complication rate for antiarrhythmic drugs.585,717,1042”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [585]
In the citing paper
“Complication rates were similar, but ablation was performed in expert centres, justifying catheter ablation as first-line therapy in selected patients with paroxysmal AF who ask for interventional therapy.”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [585]
In the citing paper
“As first-line treatment for paroxysmal AF, randomized trials showed only modestly improved rhythm outcome with catheter ablation compared to antiarrhythmic drug therapy.585,[721][722][723]”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [585]
In the citing paper
“Isthmus ablation is comparably safe and more effective than antiarrhythmic drug therapy, and is recommended for recurrent atrial flutter.[585][586][587]713”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [585]
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ResultAblation Versus Drugs: What Is the Best First-Line Therapy for Paroxysmal Atrial Fibrillation?
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MethodSymptom Under-Recognition of Atrial Fibrillation Patients in Consideration for Catheter Ablation
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“[6 10] Also, the emergence of new ablation techniques, such as cryoballoon ablation, could have promoted the use of catheter ablation instead of antiarrhythmic drugs.”
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“Furthermore, no difference in terms of complications and clinical outcomes was observed between the two groups in patients with paroxysmal AF without SHD [6,11,14,16,18].”
BackgroundPredictors and incidence of health status deterioration in patients with early atrial fibrillation
Miyama, H., Ikemura, N., Kimura, T., Katsumata, Y., Yamashita, S., Yamaoka, K., Ibe, S., Sekine, O., Ueda, I., Nakamura, I., et al. (2024) · Heart Rhythm · doi:10.1016/j.hrthm.2024.04.014 · Cited by 7
The Year in Review of Clinical Cardiac Electrophysiology
Marcus, G. M., Keung, E. C., & Scheinman, M. M. (2013) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2012.09.062 · Cited by 7
Liu, W. Y., Wu, Q. E., Yang, X., & Huang, J. (2018) · Europe PMC (PubMed Central) · doi:10.11909/j.issn.1671-5411.2018.06.011 · Cited by 7
D’Angelo, R. N., Khanna, R., Wong, C., Yeh, R. W., Goldstein, L. J., Marcello, S. R., Tung, P., d’Ávila, A., & ZIMETBAUM, P. J. (2022) · Pacing and Clinical Electrophysiology · doi:10.1111/pace.14459 · Cited by 7
Comparison of maximum-sized visually guided laser balloon and cryoballoon ablation
Ohkura, T., Yamasaki, T., Kakita, K., Hattori, T., Nishimura, T., Iwakoshi, H., Shimoo, S., Shiraishi, H., Matoba, S., & Senoo, K. (2022) · Heart and Vessels · doi:10.1007/s00380-022-02208-7 · Cited by 7
Decision-making for recurrent atrial fibrillation after catheter ablation
Ko, J. S., Kim, S. S., Jeong, H. K., & Kim, N. (2023) · Cardiovascular Prevention and Pharmacotherapy · doi:10.36011/cpp.2023.5.e15 · Cited by 9
Electrophysiological Evaluation of Thoracoscopic Pulmonary Vein Isolation.
de Groot, J. R., Berger, W. R., Krul, S. P. J., van Boven, W. J., Salzberg, S. P., & Driessen, A. H. G. (2013) · Europe PMC (PubMed Central) · doi:10.4022/jafib.899 · Cited by 7
Pandozi, C., Lavalle, C., Ficili, S., Russo, M., Galeazzi, M., Rio, T., Aznaràn, C. A. C., Malacrida, M., & Colivicchi, F. (2019) · Pacing and Clinical Electrophysiology · doi:10.1111/pace.13732 · Cited by 7
Extreme Obesity Is Associated With Low Success Rate Of Atrial Fibrillation Catheter Ablation
Lakkireddy, D. (2020) · Journal of Atrial Fibrillation · doi:10.4022/jafib.2242 · Cited by 7
Nothstein, M., Luik, A., Jadidi, A., Sánchez, J., Unger, L. A., Wülfers, E. M., Dössel, O., Seemann, G., Schmitt, C., & Loewe, A. (2021) · Frontiers in Physiology · doi:10.3389/fphys.2021.673047 · Cited by 7
Choi, J., Park, S., Park, K., Kim, J. S., & On, Y. K. (2022) · PLoS ONE · doi:10.1371/journal.pone.0265482 · Cited by 7
“However, randomized controlled trials have demonstrated the superiority of catheter ablation over AAD in maintaining sinus rhythm [6, 7].”
BackgroundHas the Time Come to Recommend Catheter Ablation of Atrial Fibrillation as First-Line Therapy?
Calkins, H. G. (2014) · JAMA · doi:10.1001/jama.2014.468 · Cited by 7
Oral anticoagulation after catheter ablation of atrial fibrillation: caught in the attribution trap?
Kirchhof, P. F., Purmah, Y., & Verma, A. (2014) · European Heart Journal · doi:10.1093/eurheartj/ehu443 · Cited by 7
Camm, A. J. (2019) · European Heart Journal · doi:10.1093/eurheartj/ehz168 · Cited by 7
The RACE to Treat Atrial Fibrillation in the Emergency Department
Healey, J. S., & McIntyre, W. F. (2019) · New England Journal of Medicine · doi:10.1056/nejme1902341 · Cited by 7
Sex disparity in referral for catheter ablation for atrial fibrillation
Gangadharan, A. A., Muhammad, L. N., Song, J., Knight, B. P., & PASSMAN, R. S. (2024) · Journal of Interventional Cardiac Electrophysiology · doi:10.1007/s10840-024-01854-3 · Cited by 6
Kallergis, E. M., & SIMANTIRAKIS, E. N. (2025) · Arrhythmia & Electrophysiology Review · doi:10.15420/aer.2025.20 · Cited by 6
Murakawa, Y., Nogami, A., Shoda, M., Inoue, K., Naito, S., Kumagai, K., Miyauchi, Y., Yamane, T., Morita, N., Mitamura, H., et al. (2013) · Journal of Arrhythmia · doi:10.1016/j.joa.2013.08.003 · Cited by 6
Selection for atrial fibrillation ablation: Importance of diastolic function grading
Pezawas, T., Binder, T. M., Ristl, R., Schneider, B., Stojković, S., Schukro, C., & Schmidinger, H. (2014) · Journal of Cardiology · doi:10.1016/j.jjcc.2014.07.018 · Cited by 6
Cunha, P. S., Teixeira, B. L., Laranjo, S. M., Portugal, G., Valente, B. T., Delgado, A. S., Pereira, M. B., Rocha, A. C., Brás, M., Cruz, M. C., et al. (2023) · Frontiers in Cardiovascular Medicine · doi:10.3389/fcvm.2023.1309900 · Cited by 6
Ma, C., Xiao, X., Chen, Q., Li, W., Wang, Z., Dai, S., Sun, Y., Xia, Y., Gao, L., & Yin, X. (2025) · Frontiers in Cardiovascular Medicine · doi:10.3389/fcvm.2025.1501716 · Cited by 6
Wilson, H. J. E., Patton, D., Moore, Z. E. H., O’Connor, T., & Nugent, L. (2020) · European Heart Journal - Cardiovascular Pharmacotherapy · doi:10.1093/ehjcvp/pvaa018 · Cited by 6
Chieng, D., Finch, S. J., Sugumar, H., Taylor, A. J., Reid, C. M., Kalman, J. M., & Kistler, P. M. (2020) · EP Europace · doi:10.1093/europace/euaa308 · Cited by 6
Clinical outcomes following rhythm control for atrial fibrillation: is early better?
Kotalczyk, A., Ding, W. Y., Gupta, D., Wright, D. J., & Lip, G. Y. H. (2021) · Expert Review of Cardiovascular Therapy · doi:10.1080/14779072.2021.1902307 · Cited by 6
Mid-term outcomes of thoracoscopic and hybrid therapy of atrial fibrillation
Revishvili, A. S., Азатовна, Т. И., Artyukhina, Е. А., Сергеевич, М. Е., Novikov, M. V., & Дмитриевна, С. Е. (2021) · Journal of Arrhythmology · doi:10.35336/va-2021-3-5-12 · Cited by 6
Song, J., Zhang, Q., Ye, L., Zheng, Y., & Wang, L. (2022) · PLoS ONE · doi:10.1371/journal.pone.0262702 · Cited by 6
“In the atrial fibrillation ablation group, there were two trial groups that were not treated with antiarrhythmic drugs prior to enrolment [16, 22].”
MethodAndrade, J. G., Chierchia, G., Kuniss, M., & Wazni, O. M. (2021) · EP Europace · doi:10.1093/europace/euab246 · Cited by 6
Yıldırım, Y., Petersen, J., Aydın, A., Alassar, Y., Reichenspurner, H. C., & Pecha, S. (2022) · Medicina · doi:10.3390/medicina58111607 · Cited by 6
“Since then, in catheter-based interventional ablation, the pulmonary veins are the main target for AF ablation [14,15].”
Background
Metadata
- Authors
- Cosedis Nielsen, J., Johannessen, A., Raatikainen, P., Hindricks, G., Walfridsson, H., Kongstad, O., Pehrson, S., Englund, A., Hartikainen, J., Mortensen, L. S., & Hansen, P. S.
- Affiliations
- Gentofte Hospital (DK)
- Tampere University Hospital (FI)
- University Hospital Leipzig (DE)
- Linköping University Hospital (SE)
- Skåne University Hospital (SE)
- Rigshospitalet (DK)
- Örebro University Hospital (SE)
- Kuopio University Hospital (FI)
- Aarhus University Hospital (DK)
- ORCID
- Venue
- New England Journal of Medicine
- Publisher
- Massachusetts Medical Society
- Published
- 2012-10-25
- Volume
- 367
- Issue
- 17
- Pages
- 1587-1595
- ISSN
- 0028-4793 (ISSN-L)
- 1533-4406
- OpenAlex
- W2164489173
- Cited by
- 720
- References
- 26
- Citations by year
- 2026: 18 · 2025: 42 · 2024: 60 · 2023: 33 · 2022: 73 · 2021: 79 · 2020: 58 · 2019: 39 · 2018: 38 · 2017: 50 · 2016: 53 · 2015: 44 · 2014: 68 · 2013: 54 · 2012: 8
- FWCI
- 35.82
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- New England Journal of Medicine (publishedVersion)
- PubMed (publishedVersion)
- Lund University Publications (Lund University) (submittedVersion, other-oa)
- Funders
- Sanofi
- Hjerteforeningen (05-4-B284-A466-22237)
- Foundation for Cardiovascular Research
- Sydäntutkimussäätiö
- St. Jude Medical
- Biosense Webster
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Arrhythmias and Treatments
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac pacing and defibrillation studies
- Keywords
- paroxysmal atrial fibrillation, radiofrequency catheter ablation, antiarrhythmic drugs, class Ic antiarrhythmic drugs, class III antiarrhythmic agents, first-line therapy, arrhythmia burden, symptomatic atrial fibrillation, cardiac tamponade
- MeSH terms
- Aged, Anti-Arrhythmia Agents, Atrial Fibrillation, Atrial Flutter, Female, Flecainide, Follow-Up Studies, Humans, Male, Middle Aged, Propafenone, Quality of Life, Electrocardiography, Ambulatory, Treatment Outcome, Catheter Ablation, Cost of Illness, Statistics, Nonparametric, Intention to Treat Analysis
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