ABLATE Versus PACE: PVI or AV Node Ablation and PM Implantation for Elderly Patients With Persistent AF

Study Overview
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Brief Summary
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As patients age, symptom control and treatment of atrial fibrillation become equally difficult, often leading to increased hospitalization. ABLATE versus PACE is a prospective, randomized clinical trial comparing pacemaker implantation with AV node ablation with pulmonary vein isolation in terms of rehospitalization and quality of life in patients with persistent AF aged 75 years and older.

Detailed Description
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Atrial fibrillation is the most common cardiac arrhythmia and is a major public and represents a major public health problem with increasing healthcare costs and increased mortality risk. In case of recurrent symptomatic atrial fibrillation current guidelines recommend pulmonary-vein isolation (PVI) as invasive treatment option. However, 5-year arrhythmia-free survival estimate is 29% after single catheter ablation. Although the long-term success rates in maintaining sinus rhythm are higher than with drug-based rhythm control, they are still moderate, especially in older patients with comorbidities. Therefore, repeated interventions are often necessary. An effective method for frequency control is atrioventricular (AV) node ablation after implantation of a pacemaker (ablate-and-pace). In this case, the ventricular rate is only set by the pacemaker and can be programmed according to the patient's needs. There are some theoretical disadvantages of this treatment option (pacemaker dependency, reduction of cardiac outpout due to lack of atrial contraction) which is why this method nowadays is almost exclusively used in older (and physically less active) patients. The ABLATE versus PACE trial is a prospective randomized clinical trial comparing at 196 these two treatment options in terms of rehospitalizations due to cardiovascular causes and quality of life in elderly patients (≥ 75 years) with normal ejection fraction (≥ 50%).

Official Title
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Pulmonary-vein Isolation or Ablation of Atrioventricular-node and Pacemaker Implantation for Elderly Patients With Persistent Atrial Fibrillation (ABLATE Versus PACE)

Conditions
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Atrial Fibrillation

Intervention / Treatment
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* Procedure: Cryoballoon pulmonary-vein isolation
* Procedure: Pacemaker implantation and ablation of atrioventricular-node


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Persistent AF (duration < 12 months) according to current ESC guideline (2020) Symptoms EHRA classification II - IV Age ≥ 75 years Capability of giving written informed consent Exclusion Criteria: impaired systolic left ventricular function (ejection fraction < 50%) High-grade (III°) left cardiac valvular disease pre-implanted pacemaker bradycardia-indication for pacemaker Surgical coronary revascularization (within the last 90 days) or current triple therapy after stent PCI contraindication for PVI or pacemaker-implantation contraindication for oral anticoagulation body-mass-index BMI > 35 kg/m2 inability to give written informed consent concomitant participation in another registered trial life expectancy < 12 months reversible cause of AF (e.g. thyrotoxicosis, alcohol ingestion)

Ages Eligible for Study
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Minimum Age: 75 Years
Maximum Age: 99 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Cryoballoon pulmonary-vein isolation<br> | Procedure: Cryoballoon pulmonary-vein isolation<br>* Electrical isolation of the pulmonary-veins using cryoenergy<br>|
| Active Comparator: Ablation of atrioventricular-node and pacemaker implantation<br> | Procedure: Pacemaker implantation and ablation of atrioventricular-node<br>* Pacemaker implantation and ablation of atrioventricular-node<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of subjects with any hospitalization due to atrial fibrillation, atrial tachycardia or flutter after blanking period or cardiac decompensation requiring inpatient treatment | except for protocol-indicated AVN ablation | 36 months | 
| Number of subjects requiring repeat ablation, electrical or pharmacological cardioversion for symptomatic relapse of atrial fibrillation, atrial tachycardia or flutter after blanking period |  | 36 months | 
| Number of subjects requiring upgrade to cardiac resynchronization therapy pacemaker due to reduced systolic left ventricular function with ejection fraction ≤35% in ablate-and-pace group |  | 36 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Death from any cause |  | 36 months | 
| Number of subjects with procedure-associated complications | (major bleeding by Bleeding Academic Research Consortium Definition (BARC ≥ 2) criteria, major groin site complications prolonging inpatient stay, pacemaker pocket bleeding prolonging inpatient stay, pericardial effusion, cerebrovascular or systemic embolism, phrenic nerve palsy, lead dislodgment, lead perforation, infection including pacemaker pocket infection, lead infection / pacemaker related endocarditis) | 36 months | 
| Number of subjects with nonfatal or fatal stroke/ transient ischemic attack (TIA) |  | 36 months | 
| Quality of life as assessed by Atrial Fibrillation Effect on Quality-of-Life questionnaire (AFEQT) | Scale 20-140 with higher score indicating worse quality-of-life. | 36 months | 
| Deterioration of systolic LV function ≥10 percent |  | 36 months | 
| Number of subjects requiring repeat ablation |  | 36 months | 
| Number of subjects requiring anti-arrhythmic drug treatment after initial ablation |  | 36 months |