Effect of Catheter Ablation vs Antiarrhythmic Drug Therapy on Mortality, Stroke, Bleeding, and Cardiac Arrest Among Patients With Atrial Fibrillation: The CABANA Randomized Clinical Trial | Atrial Fibrillation | JAMA | JAMA Network
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Figure 1.  Randomization and Patient Flow in the CABANA Trial
Randomization and Patient Flow in the CABANA Trial

aSites were not required to provide screening logs during the recruitment phase; thus, the number of patients assessed for eligibility is not available.

bTwenty five patients underwent repeat catheter ablation during the blanking period; 190 patients had at least 1 repeat catheter ablation during the postblanking period for a total of 215.

cOutcomes of patients who did not complete the study (ie, withdrew consent or were lost to follow-up) were included to the point of consent withdrawal or final contact. Primary and key secondary end points were analyzed using time-to-event methodology; thus, all available follow-up information was used. For patients who did not complete the study and did not experience an outcome event, their time-to-event measure was censored at the last contact date. There was no imputation of outcome events. At the end of the trial, a publicly available death registry search was performed for patients enrolled in North America who were lost or withdrew from the trial.

Figure 2.  Kaplan-Meier Estimates of the Incidence of the Primary End Point
Kaplan-Meier Estimates of the Incidence of the Primary End Point

Kaplan-Meier estimates of the cumulative risk of death, disabling stroke, serious bleeding, or cardiac arrest (primary end point by intention-to-treat analysis). The median (25th, 75th percentile) length of patient follow-up was 4.1 years (2.5, 5.1) in the catheter ablation group and 4.0 years (2.5, 5.2) in the drug therapy group.

Figure 3.  Kaplan-Meier Estimates of All-Cause Mortality and Mortality or Cardiovascular Hospitalization by Intention-to-Treat Analysis
Kaplan-Meier Estimates of All-Cause Mortality and Mortality or Cardiovascular Hospitalization by Intention-to-Treat Analysis

A, The median (25th, 75th percentiles) length of patient follow-up was 4.1 years (2.5, 5.1) in the catheter ablation group and 4.0 years (2.5, 5.2) in the drug therapy group. B, The median (25th, 75th percentiles) length of patient follow-up was 4.1 years (2.5, 5.1) in the catheter ablation group and 4.0 years (2.5, 5.2) in the drug therapy group.

Figure 4.  Primary End Point Subgroup Analysis (Intention to Treat)
Primary End Point Subgroup Analysis (Intention to Treat)

The squares represent the hazard ratios and the bars indicate the 95% CIs. AF indicates atrial fibrillation; CHA2DS2-VASc, congestive heart failure, hypertension, age ≥75 years (doubled), diabetes, stroke/transient ischemic attack/thromboembolism (doubled), vascular disease (prior myocardial infarction, peripheral artery disease, or aortic plaque), age 65-75 years, sex category (female); LVH, left ventricular hypertrophy; NYHA, New York Heart Association.

aMinority = Hispanic or Latino or nonwhite race. Minority status was determined by the site investigator in conjunction with the patient based on predefined categories as required by the National Institutes of Health (NIH) using NIH-specified categories.

bParoxysmal = AF episodes lasting ≥1 hour in duration that terminate spontaneously within 7 days or cardioversion is performed within 48 hours of AF onset. Persistent = AF episode sustained for ≥7 days or cardioversion is performed more than 48 hours after AF onset. Long-standing persistent = continuous AF >1 year in duration.

cOn a scale of I to IV, with I indicating the least severe and IV, the most severe symptoms of heart failure.

dOn a scale of 0 to 9, with 0 indicating the lowest risk of stroke and 9, the highest risk of stroke.

eCalculated as weight in kilograms divided by height in meters squared.

Figure 5.  Kaplan-Meier Estimates of the Primary End Point by Per-Protocol Analysis
Kaplan-Meier Estimates of the Primary End Point by Per-Protocol Analysis

Kaplan-Meier estimates of the cumulative risk of death, disabling stroke, serious bleeding, or cardiac arrest (primary end point) by 6-month (A) and 12-month (B) per-protocol analysis. Figure includes patients randomized to catheter ablation who were ablated within 6 months (A) or 12 months (B) after randomization. It also includes all patients randomized to drug therapy, with follow-up censored at crossover to ablation. A, The median (25th, 75th percentiles) length of patient follow-up was 4.1 years (2.6, 5.2) in the catheter ablation group and 4.0 years (2.5, 5.2) in the drug therapy group. B, The median (25th, 75th percentiles) length of patient follow-up was 4.2 years (2.6, 5.2) in the catheter ablation group and 4.0 years (2.5, 5.2) in the drug therapy group.

Figure 6.  Recurrent Atrial Fibrillation After Blanking by Intention-to-Treat Analysis
Recurrent Atrial Fibrillation After Blanking by Intention-to-Treat Analysis

Freedom from recurrence of atrial fibrillation following the blanking period in 1240 patients who used the study electrocardiogram event recorders (intention-to-treat analysis with death as a competing risk). The median (25th, 75th percentiles) length of patient follow-up was 4.3 years (2.8, 5.0) in the catheter ablation group and 4.3 years (2.7, 5.3) in the drug therapy group.

Table 1.  Baseline Demographics and Clinical Characteristics
Baseline Demographics and Clinical Characteristics
Table 2.  Primary and Secondary Outcomes by Intention-to-Treat Analysis
Primary and Secondary Outcomes by Intention-to-Treat Analysis
Supplement 3.

eTable 1. CABANA Inclusion/Exclusion Criteria

eTable 2. CABANA Secondary End Points

eTable 3. Baseline Characteristics of Patients Randomized to Ablation Who Did vs Did Not Receive the Ablation

eTable 4. Rate and Rhythm Control Drug Use in the CABANA Treatment Groups (As Randomized) (A) At Enrollment and (B) During Follow-up After the Blanking Period

eTable 5. Baseline Characteristics of Patients Randomized to the Drug Group Who Did vs Did Not Cross Over to Ablation

eTable 6. Reasons for CABANA Cardiovascular Hospitalizations

eTable 7. Deaths and Strokes in CABANA Patients (As Randomized) With An Event < 30 Days Following Treatment vs Later During Follow-up

eTable 8. Results of Treatment Received and Per-Protocol Analyses

eTable 9. Adverse Events in Patients Randomized to Drug Therapy

eTable 10. Adverse Events in Patients Randomized to Ablation

eTable 11. Anticoagulant and Antiplatelet Use in the CABANA Treatment Groups (As Randomized) (A) At Enrollment and (B) During Follow-up After Randomization

eFigure 1. Kaplan-Meier Estimates of Mortality (Per Protocol)

eFigure 2. Subgroup analysis with hazard ratios and 95% confidence intervals for the primary endpoint by Per-Protocol analysis

eFigure 3. Recurrent Atrial Arrhythmias Post-Blanking (ITT)

eFigure 4. Forest Plot of Recurrent AF

eFigure 5. Modified CONSORT Diagram for ITT Analyses

eFigure 6. Modified CONSORT Diagram for Treatment Received Analyses

eFigure 7. Modified CONSORT Diagram for Per-Protocol Analyses

eAppendix 1. Commentary on Statistical Analyses

eAppendix 2. Trial Organization

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    1 Comment for this article
    EXPAND ALL
    Enough To Change Practice?
    Michael Berkwits, MD, MSCE | JAMA
    The 2 reports from the CABANA trials, combined with that from the CAPTAF trial published simultaneously in the March 19 JAMA issue (1), provide a surplus of data about the comparative effects of PVI ablation vs. antiarrythmic therapy for management of atrial fibrillation. An accompanying editorial capably sums up where the findings leave clinicians: "In experienced centers, when performed by skilled operators with low procedural complication rates as achieved in CABANA, catheter ablation can be performed successfully and safely in most patients. For patients with symptoms, in whom quality of life is impaired by AF, catheter ablation can improve quality of life to a greater extent than drug therapy. However, patients who choose drug therapy will also likely experience significant improvements in quality of life and have no worse risk for the most concerning complications of AF, stroke and death. Thus, there is no mandate for patients [currently on drug therapy] to undergo catheter ablation at this time."

    Will or should these data change the general management approach to afib patients? JAMA welcomes your comments and insights.

    References

    1. Blomström-Lundqvist C, Gizurarson S, Schwieler J, et al. Effect of Catheter Ablation vs Antiarrhythmic Medication on Quality of Life in Patients With Atrial Fibrillation: The CAPTAF Randomized Clinical Trial. JAMA;2019;321(11):1059-1068. doi:10.1001/jama.2019.0335. https://jamanetwork.com/journals/jama/fullarticle/2728485
    CONFLICT OF INTEREST: JAMA Electronic Editor
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    Original Investigation
    March 15, 2019

    Effect of Catheter Ablation vs Antiarrhythmic Drug Therapy on Mortality, Stroke, Bleeding, and Cardiac Arrest Among Patients With Atrial Fibrillation: The CABANA Randomized Clinical Trial

    Author Affiliations
    • 1Mayo Clinic, Rochester, Minnesota
    • 2Duke Clinical Research Institute, Duke University, Durham, North Carolina
    • 3University of Washington Medical Center, Seattle
    • 4National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
    • 5Libin Cardiovascular Institute of Alberta, Calgary, Alberta, Canada
    • 6University of Missouri, Columbia
    • 7E. Meshalkin National Medical Research Center of the Ministry of Health of the Russian Federation, Novosibirsk, Russia
    • 8Intermountain Health Care, Salt Lake City, Utah
    • 9Herz-und Diabeteszentru, Bad Oeynhausen, Germany
    • 10Medical Science Center of Moscow State University, Moscow, Russia
    • 11Bakoulev Center for Cardiovascular Surgery, Moscow, Russia
    • 12Loyola University Medical Center, Maywood, Illinois
    • 13Humanitas Rozzano-Milano, Milan, Italy
    • 14Asklepios Klinik St Georg, Hamburg, Germany
    • 15Leipzig Heart Center, Leipzig, Germany
    • 16St Marys Hospital, London, United Kingdom
    • 17Sidney Kimmel Medical College, Thomas Jefferson University, Wynnewood, Pennsylvania
    • 18Penn State University, Hershey, Pennsylvania
    • 19Columbia University, New York, New York
    JAMA. 2019;321(13):1261-1274. doi:10.1001/jama.2019.0693
    Key Points

    Question  Among patients with atrial fibrillation, what is the effect of catheter ablation, compared with medical therapy, on cardiovascular events and mortality?

    Findings  In this randomized clinical trial involving 2204 patients with atrial fibrillation, catheter ablation, compared with medical therapy, did not significantly reduce the primary composite end point of death, disabling stroke, serious bleeding, or cardiac arrest (8.0% vs 9.2%, respectively; hazard ratio, 0.86).

    Meaning  Among patients with atrial fibrillation, catheter ablation, compared with medical therapy, did not significantly reduce the primary composite outcome.

    Abstract

    Importance  Catheter ablation is effective in restoring sinus rhythm in atrial fibrillation (AF), but its effects on long-term mortality and stroke risk are uncertain.

    Objective  To determine whether catheter ablation is more effective than conventional medical therapy for improving outcomes in AF.

    Design, Setting, and Participants  The Catheter Ablation vs Antiarrhythmic Drug Therapy for Atrial Fibrillation trial is an investigator-initiated, open-label, multicenter, randomized trial involving 126 centers in 10 countries. A total of 2204 symptomatic patients with AF aged 65 years and older or younger than 65 years with 1 or more risk factors for stroke were enrolled from November 2009 to April 2016, with follow-up through December 31, 2017.

    Interventions  The catheter ablation group (n = 1108) underwent pulmonary vein isolation, with additional ablative procedures at the discretion of site investigators. The drug therapy group (n = 1096) received standard rhythm and/or rate control drugs guided by contemporaneous guidelines.

    Main Outcomes and Measures  The primary end point was a composite of death, disabling stroke, serious bleeding, or cardiac arrest. Among 13 prespecified secondary end points, 3 are included in this report: all-cause mortality; total mortality or cardiovascular hospitalization; and AF recurrence.

    Results  Of the 2204 patients randomized (median age, 68 years; 37.2% female; 42.9% had paroxysmal AF and 57.1% had persistent AF), 89.3% completed the trial. Of the patients assigned to catheter ablation, 1006 (90.8%) underwent the procedure. Of the patients assigned to drug therapy, 301 (27.5%) ultimately received catheter ablation. In the intention-to-treat analysis, over a median follow-up of 48.5 months, the primary end point occurred in 8.0% (n = 89) of patients in the ablation group vs 9.2% (n = 101) of patients in the drug therapy group (hazard ratio [HR], 0.86 [95% CI, 0.65-1.15]; P = .30). Among the secondary end points, outcomes in the ablation group vs the drug therapy group, respectively, were 5.2% vs 6.1% for all-cause mortality (HR, 0.85 [95% CI, 0.60-1.21]; P = .38), 51.7% vs 58.1% for death or cardiovascular hospitalization (HR, 0.83 [95% CI, 0.74-0.93]; P = .001), and 49.9% vs 69.5% for AF recurrence (HR, 0.52 [95% CI, 0.45-0.60]; P < .001).

    Conclusions and Relevance  Among patients with AF, the strategy of catheter ablation, compared with medical therapy, did not significantly reduce the primary composite end point of death, disabling stroke, serious bleeding, or cardiac arrest. However, the estimated treatment effect of catheter ablation was affected by lower-than-expected event rates and treatment crossovers, which should be considered in interpreting the results of the trial.

    Trial Registration  ClinicalTrials.gov Identifier: NCT00911508

    Introduction

    Quiz Ref IDAtrial fibrillation (AF) is not only the most common cardiac tachyarrhythmia, but also the most perplexing from a clinical management perspective. Some patients with AF are symptomatic to the point of disabling decrements in quality of life, while others remain asymptomatic. In epidemiologic studies, AF also has significant adverse prognostic effects and has been associated with poor outcomes including reduced survival1-3 and an increased risk of major nonfatal cardiac morbidities, including stroke, congestive heart failure, and late cognitive impairment. How much this risk can be mitigated by restoring sinus rhythm remains uncertain.

    Antiarrhythmic drug therapy has been the primary treatment for AF for decades, but limited effectiveness combined with incompletely assessed risks have led to the development of other strategies to maintain sinus rhythm. Starting in 1998, reports appeared suggesting that ablative intervention was more effective than antiarrhythmic drug therapy in reducing episodes of recurrent paroxysmal AF.4-8 Since those early reports, the use of ablation has been extended to more difficult and higher-risk patients9 despite the lack of large randomized comparative trial evidence of improved clinical outcomes. Recently, a small trial of ablation vs medical therapy in symptomatic patients with AF and class II or worse systolic heart failure provided evidence suggesting that successful ablation may extend survival.10

    The Catheter Ablation vs Antiarrhythmic Drug Therapy for Atrial Fibrillation (CABANA) trial, an investigator-initiated, multicenter, prospective, randomized, open-label clinical trial funded by the National Heart, Lung, and Blood Institute and industry partners, was designed to test the hypothesis that ablative therapy for AF is more effective than state-of-the-art drug therapy in a broad population of symptomatic and inadequately treated patients with AF.11

    Methods
    Trial Design and Setting

    Each site’s institutional review board or ethics committee approved the study. Written informed consent was obtained from all patients. The trial protocol and statistical analysis plan are available in Supplement 1 and trial protocol amendments in Supplement 2. Details of the trial design have also been previously published.11 Race and ethnicity were classified by the patient and investigators as required by the National Institutes of Health (NIH) using NIH-specified categories.

    Quiz Ref IDEligible patients were aged 65 years and older or younger than 65 years with 1 or more risk factors for stroke (hypertension, heart failure, history of stroke, diabetes, or other heart problems), had 2 or more episodes of paroxysmal AF or 1 episode of persistent AF in the prior 6 months, and were suitable for catheter-based treatment or rhythm and/or rate control drug therapy. Patients were excluded if they had a prior left atrial catheter ablation for AF or had failed 2 or more antiarrhythmic drugs. Full eligibility criteria are listed in eTable 1 in Supplement 3. Eligible patients were randomized in equal proportions to either catheter ablation or drug therapy using permuted block randomization with stratification by clinical site. The block size (concealed from investigators) was randomly selected with equal probability between 2 and 4. Randomization was accomplished using a centralized, interactive voice response and web-based randomization system (IXRS; Almac). By protocol, ablation procedures all included pulmonary vein isolation. The addition of ancillary ablation techniques, including linear, ganglion plexus, and electrogram-based approaches, were left to the discretion of the investigators.4,12 Physicians performing ablations were required to have a 100-case experience to participate in the trial. It was recommended that patients randomized to medical therapy receive rate control medications first. If the patient had previously failed rate control therapy, then rhythm control drug therapy could be initiated in an approach consistent with contemporaneous guidelines.

    All patients were to receive anticoagulation based on contemporaneous guidelines.13,14 Patients who received a catheter ablation were treated with anticoagulation for at least 3 months after the ablation, with a recommendation that this be continued throughout the trial in patients with CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years [doubled], diabetes, stroke/transient ischemic attack/thromboembolism [doubled], vascular disease [prior myocardial infarction, peripheral artery disease, or aortic plaque], age 65-75 years, sex category [female]) scores of 2 or more, following recommendations of the American Heart Association/American College of Cardiology/European Society of Cardiology guidelines13 and guidelines from the ablation consensus documents.12,15,16 Details of medical treatments used in the trial are provided in the trial design paper.11

    The trial originally planned to enroll 3000 patients who would be followed up for approximately 3 years with a primary end point of all-cause mortality.11 Based on information available during the design phase of the trial, the mortality rate in the drug group was projected to be approximately 12% after 3 years of follow-up.11 We hypothesized that there would be a 30% relative risk reduction in patients treated with ablation based on synthesis of information from multiple published sources, as described in the trial design paper.11

    Due to slow enrollment and lower than expected aggregated event rates, the data and safety monitoring board, after completing a scheduled review of trial progress in early 2013, recommended modifying the trial design. In response, the study leadership, blinded to treatment-specific outcomes, modified the design in February 2013 by (1) elevating the key secondary end point (composite of death, disabling stroke, serious bleeding, or cardiac arrest) to the primary end point, (2) changing all-cause mortality to the key secondary end point, and (3) extending study follow-up to an average of 4 years or longer, all of which supported a reduction in the sample size to 2200 patients. The new primary end point event rate was expected to be equal to or greater than the originally anticipated mortality rate, and the effect of ablation was again assumed to be a 30% relative reduction. These projections assumed up to 25% treatment crossover from drug therapy to ablation while maintaining the desired 90% level of statistical power.11

    Scheduled patient follow-up occurred at 3, 6, and 12 months and then every 6 months thereafter. All events for each component of the primary end point were reviewed and adjudicated in a blinded fashion by an independent clinical events committee using prospectively determined event definitions. Death was defined as all-cause mortality, disabling stroke (including intracranial bleeding) as an irreversible physical limitation defined by a Rankin Stroke Scale score of 2 or greater, and serious bleeding as bleeding accompanied by hemodynamic compromise requiring surgical intervention or a transfusion of 3 or more units of blood.

    Three of 13 prespecified secondary end points of the trial are reported in this article: overall mortality, overall mortality or cardiovascular (CV) hospitalization, and AF recurrence (based on the subset of patients with the CABANA electrocardiogram [ECG] event recording system). The reason for hospitalization was characterized by the site principal investigator and reported on the hospitalization case report form. To determine AF recurrence rates, patients were provided with an ECG event recorder for chronicling symptomatic events; for 24-hour autodetect, full-disclosure, real-time recordings on a quarterly basis; and to obtain 96-hour Holter recordings every 6 months regardless of symptoms. Monitoring algorithms provided beat-to-beat morphologic analyses as well as rate and rhythm information. In countries that prohibited the use of the trial event recording system for regulatory reasons, largely equivalent, standard ECG event recording systems were used. Over the course of follow-up, a 30-second episode of AF in either treatment group, confirmed through blinded review by an ECG Core Laboratory Committee, was used to define the end point of recurrent AF.

    In the analysis of long-term AF recurrence, a conventional 3-month blanking period from therapy initiation was used in both treatment groups during which arrhythmia recurrences were not counted toward the recurrent AF end point. A repeat ablation for recurrent AF could be performed during this time if necessary. Similarly, patients randomized to drug therapy were allowed serial drug trials during the blanking period to find an effective, best-tolerated regimen. All other end points, including adverse events, were chronicled from the time of randomization.

    Quality-of-life outcomes are reported in a companion article.17 Other secondary end points (eTable 2 in Supplement 3) will be reported in future publications.

    Statistical Methods
    Prespecified Primary, Secondary, and Subgroup Analyses by Intention to Treat

    The primary treatment comparisons between the randomized groups were performed according to the intention-to-treat (ITT) principle based on a time-to-first-event analysis using the log-rank test.18 Kaplan-Meier cumulative event rates19 were calculated for each group, with event or censoring times measured from the time of randomization. Relative risks were expressed as hazard ratios [HRs] with associated 95% CIs derived using the Cox proportional hazards model.20 The proportional hazards assumption of the model was checked by examining a treatment by (log) time interaction term and by assessing Schoenfeld residuals,21 as detailed in eAppendix 1 in Supplement 3. The Cox model was also used to assess the consistency of treatment effects by testing for interactions between treatment strategy and prespecified baseline characteristics. Recurrent atrial arrhythmia incidence rates were calculated from the end of the blanking period by ITT, and adjusted statistical comparisons were performed with mortality as a competing risk.22

    Two-sided significance testing was used with a conventional significance level of .05, unless otherwise specified. There was no adjustment for multiple comparisons among the secondary end points (eAppendix 1 in Supplement 3).

    For patients who withdrew consent or were lost to follow-up during the study, all information collected to the point of consent withdrawal or final contact was analyzed. For patients who did not complete the study and did not experience an outcome event, their time-to-event measure was censored at the last contact date. Imputation of outcome events was not performed.

    Prespecified Sensitivity Analyses

    “Treatment received” comparisons were performed using the Cox model with catheter ablation included as a time-dependent covariate. “Per-protocol” comparisons were performed in which the drug group consisted of all patients randomized to drug therapy, with the follow-up of patients who received drug therapy and crossed over to catheter ablation censored at the time of ablation. The per-protocol catheter ablation group included patients randomized to catheter ablation who received an ablation within the 6-month time window following randomization. As prespecified, a shorter window (3 months) and a longer window (12 months) were also considered. The prespecified treatment received and per-protocol treatment comparisons were adjusted for a prespecified set of baseline patient characteristics (age, sex, race/ethnicity, AF type, years since onset of AF, history of heart failure, structural heart disease, CHA2DS2-VASc score, history of coronary artery disease, and hypertension). Additional details on these analyses are provided in eAppendix 1 in Supplement 3.

    Post Hoc Sensitivity Analysis

    To evaluate the possibility that treatment effect varied among the 126 enrolling sites, we performed a post hoc ITT mixed-model analysis of the primary end point comparison adjusted for enrolling site as a random effect.

    Trial Monitoring

    An independent data and safety monitoring board appointed by the National Heart, Lung, and Blood Institute performed interim reviews of the study at regular intervals during the trial. One formal interim treatment comparison of primary end point data was performed and monitored with the use of 2-sided, symmetric O’Brien-Fleming23 boundaries generated with the Lan-DeMets α-spending function approach to group sequential testing.24 A significance level of .049 was required for the primary end point at the final analysis to adjust for the interim analysis.

    All analyses were performed using SAS software version 9.4 or later versions (SAS Institute).

    Results
    Study Population

    Between November 2009 and April 2016, 2204 patients from 126 sites across 10 countries were randomly assigned to receive catheter ablation (1108 patients) or drug therapy (1096 patients) (Figure 1). Follow-up continued through December 31, 2017, for a median duration of 48.5 months (25th percentile: 29.9 months, 75th percentile: 62.1 months).

    Characteristics at Baseline

    The 2 treatment groups showed the balance in baseline factors expected from randomization (Table 1). The patients randomized to catheter ablation had a median age of 68 years, 37.3% were women, and 10.2% belonged to racial or ethnic minorities. The patients randomized to drug therapy had a median age of 67 years, 37.0% were women, and 10.2% belonged to racial or ethnic minorities. Paroxysmal AF was present in 42.4% of patients in the catheter ablation group and 43.5% in the drug therapy group, with the remainder having persistent or long-standing persistent AF (Table 1). The study population had a substantial burden of CV risk factors (Table 1): 80.6% with hypertension, 25.5% with diabetes, 19.2% with coronary artery disease, 10.0% with a prior stroke or transient ischemic attack, 15.3% with history of congestive heart failure, and 56.5% with a CHA2DS2-VASc score greater than 2 (median, 3).

    Treatments

    Among the 1108 patients randomly assigned to the catheter ablation group, 1006 (90.8%) underwent ablation at a median of 29 days following randomization, and 102 patients did not receive ablation due to patient or family refusal (82.4%) or physician decision (13.7%) (see eTable 3 in Supplement 3 for a comparison of patients who did vs did not undergo ablation). Among the catheter ablation patients, 25 underwent repeat ablation during the blanking period, with 190 patients undergoing at least 1 repeat ablation during the postblanking period, for a total of 215 patients (19.4%) with repeat procedures (Figure 1). Among the catheter ablation patients, 44.6% also received antiarrhythmic drugs at some point during the postblanking period (eTable 4 in Supplement 3), but only 26.5% of the catheter ablation patients were still taking an antiarrhythmic drug at last follow-up.

    Among the 1096 patients assigned to the drug therapy group, 1092 (99.6%) received drug therapy, with 545 receiving 1 antiarrhythmic drug, 296 receiving 2, 106 receiving 3, and 22 receiving 4 or more different antiarrhythmic drugs over the course of the trial (eTable 4 in Supplement 3). Most patients (n = 969 [88.4%]) in the drug therapy group received rhythm control drugs during the trial. A total of 301 drug therapy patients (27.5%) crossed over to catheter ablation during the follow-up period (Figure 1). A comparison of these patients and other patients exclusively treated with drugs is provided in eTable 5 in Supplement 3.

    ITT (As Randomized) Treatment Comparisons

    A primary outcome event occurred in 89 patients (8.0%) in the catheter ablation group and in 101 patients (9.2%) in the drug therapy group (HR for ablation vs drug therapy, 0.86 [95% CI, 0.65-1.15]; log-rank P = .30) (Table 2 and Figure 2). Four-year Kaplan-Meier event rates were 7.2% for catheter ablation and 8.9% for drug therapy patients (absolute difference, 1.7%; Table 2). For the key secondary end point of all-cause mortality, a total of 58 patients (5.2%) in the catheter ablation group and 67 patients (6.1%) in the drug therapy group died during follow-up (HR, 0.85 [95% CI, 0.60-1.21]; log-rank P = .38) (Table 2 and Figure 3A). Four-year mortality rates were 4.7% for catheter ablation and 5.3% for drug therapy patients (absolute difference, 0.6%; Table 2). The composite secondary end point of death from any cause or CV hospitalization occurred in 573 patients (51.7%) in the catheter ablation group and 637 patients (58.1%) in the drug therapy group (HR, 0.83 [95% CI, 0.74-0.93]; log-rank P = .001), with 4-year rates of 54.9% for catheter ablation and 62.7% for drug therapy patients (absolute difference, 7.8%; Table 2 and Figure 3B). Details regarding the causes of CV hospitalizations are provided in eTable 6 in Supplement 3.

    Adjustment for site as a random effect (post hoc analysis) did not change the estimated treatment effect (HR, 0.86 [95% CI, 0.64-1.15]; Wald test P = .29).

    Subgroup Analysis

    Examination of prespecified subgroups based on clinical and demographic characteristics did not identify relative variations in the treatment effect of ablation large enough to be clinically significant while also possessing sufficient precision to exclude the null effect (ie, HR, 1) (Figure 4).

    Treatment Received Analyses

    In the prespecified treatment received analyses, the HR for catheter ablation vs drug therapy with respect to the primary end point was 0.67 (95% CI, 0.50-0.89; P = .006). For all-cause mortality, the corresponding HR was 0.60 (95% CI, 0.42-0.86; P = .005) and for death or CV hospitalization, the HR was 0.83 (95% CI, 0.74-0.94; P = .002). No deaths occurred in the first 30 days after initiation of drug therapy or catheter ablation. One disabling stroke occurred in the drug therapy group within the first 30 days of treatment (eTable 7 in Supplement 3).

    Per-Protocol Treatment Comparisons

    In per-protocol treatment comparisons, patients randomized to catheter ablation who received ablation within a designated window following randomization were compared with patients randomized to the drug therapy group. For the 6-month protocol window, the HR for catheter ablation vs drug therapy for the primary end point was 0.74 (95% CI, 0.54-1.01) (Figure 5A). For the 12-month per-protocol window, the corresponding HR was 0.73 (95% CI, 0.54-0.99) (Figure 5B). The per-protocol HRs for the key secondary end point of all-cause mortality were 0.69 (95% CI, 0.47-1.01) and 0.68 (95% CI, 0.47-0.99) for the 6-month and 12-month definitions of a protocol ablation procedure, respectively (eFigure 1 and eTable 8 in Supplement 3). The subgroup assessment for the primary end point by per-protocol analysis is shown in eFigure 2 in Supplement 3.

    AF Recurrence

    In 1240 patients using the study ECG event recording system, the secondary end point of postblanking AF (time to first recurrence) analyzed by ITT with death as a competing risk was reduced by 48% with catheter ablation compared with drug therapy (adjusted HR, 0.52 [95% CI, 0.45-0.60]; P < .001) (Figure 6). The adjusted HR for the postblanking incidence of either AF, atrial flutter, or atrial tachycardia was 0.53 (95% CI, 0.46-0.62; P < .001) (eFigure 3 in Supplement 3). Fifty seven percent of patients had persistent or long-standing persistent AF at the beginning of the trial, which was reduced to 26% in drug therapy and 16% in catheter ablation patients at trial completion. The benefits of catheter ablation on recurrent AF were consistent across prespecified subgroups (eFigure 4 in Supplement 3).

    Adverse Events

    Non–end point adverse events are enumerated in eTables 9 and 10 in Supplement 3. The most common serious adverse event in the catheter ablation group was cardiac tamponade (0.8%). Other adverse events in the catheter ablation group included minor hematomas (2.3%) and pseudoaneurysms (1.1%). In the drug therapy group, thyroid disorders were reported in 1.6% and proarrhythmia in 0.8% of patients.

    Discussion

    Quiz Ref IDAmong patients with AF, catheter ablation, compared with medical therapy, did not significantly reduce the primary composite outcome. Relative to medical management, randomization to a strategy of AF ablation in this trial was associated with a 14% relative reduction in the primary composite end point, with a 95% CI for the effect that extended from a 35% lower to a 15% higher risk for catheter ablation. Because the confidence interval for the primary effect estimate lacks the precision to exclude a null effect (HR, 1.0), the trial primary ITT statistical comparison is inconclusive.25 The 4-year Kaplan-Meier event rates for the primary end point were 7.2% for catheter ablation and 8.9% for drug therapy, with an absolute treatment difference of 1.7% (HR, 0.86 [95% CI, 0.65-1.15]).

    In addition to the primary outcome results, this article describes results for 3 of 13 prespecified secondary end point comparisons. Quality-of-life outcomes are reported separately.17 For the secondary end point of all-cause mortality, catheter ablation, compared with drug therapy, in the ITT analysis had an HR of 0.85 (95% CI, 0.60-1.21). The 4-year Kaplan-Meier mortality rates were 4.7% for the catheter ablation group and 5.3% for the drug therapy group. The secondary end point of mortality or CV hospitalization showed a significant 17% relative lower event rate for the catheter ablation group. There were no differences in serious bleeding between treatment groups, and disabling strokes were infrequent, although directionally favoring the catheter ablation group, as seen in other studies.10 The small number of strokes may be due to background therapy or a high level of adherence to ongoing anticoagulation (eTable 11 in Supplement 3).

    The trial was originally projected to be able to detect a 30% mortality reduction with catheter ablation, assuming a 4% per year drug therapy mortality rate (approximately 12% at 3 years), based on previous AF trial data.11 Lower precision of the effect size estimate and an inconclusive statistical result for the primary end point by ITT is a predictable consequence of the lower-than-expected drug therapy group mortality rates (4.1% at 3 years).

    Treatment Assignment Sensitivity Analyses

    ITT-based analyses preserve the benefit of randomization in protecting from treatment selection biases, but the results may be seriously biased by postrandomization crossovers and deviations from protocol-specified care.26 For example, a catheter ablation patient who does not get an ablation remains assigned to the ablation arm in an ITT analysis, but cannot provide any information about the prognostic benefits of ablation. No completely satisfactory solution exists for such complexities. Useful insights can be obtained by examining ITT analysis results in combination with sensitivity analyses on the ITT estimates using the treatment actually received and also by comparing treatment outcomes of the patient groups who followed the treatment-assignment protocol. In this trial, the smaller ITT relative treatment effect size (15% reduction in mortality rather than the 30% predicted) may be at least partially due to postrandomization biases created by patients crossing over from their assigned treatment group (9.2% of catheter ablation patients declined their assigned procedure and 27.5% of drug therapy patients crossed over to ablation) (Figure 1). The treatment received and per-protocol analyses resulted in HR estimates ranging from 0.60 to 0.69, respectively, for catheter ablation, compared with drug therapy, with respect to mortality and HRs ranging from 0.67 to 0.74, respectively, for the primary end point. The treatment received and per-protocol analyses potentially mitigate different forms of bias present in the ITT estimate of the treatment effect size but may add biases if compliance with treatment assignment is correlated with outcome independent of treatment effects.26

    Decisions about use of catheter ablation in individual patients need to consider both relative and absolute treatment differences as well as procedural risks. Given the 4-year Kaplan-Meier event rates, for many patients meeting the eligibility criteria of this trial, expected treatment differences on an absolute scale will likely not be of sufficient magnitude to support a recommendation for catheter ablation on that basis alone.

    Prior Randomized and Observational Comparisons of Catheter Ablation and Drug Therapy

    The improvement in mortality or CV hospitalization outcomes, a secondary end point in CABANA, complements prior reports from the CASTLE-AF trial,10 as well as observational3 and randomized27,28 studies and a recent large, multiyear registry.29 A recent analysis of a US administrative database with 186 760 patients with AF treated with either ablation or drug therapy during the same years CABANA was conducted found a robust 25% relative reduction in the same composite end point used for this trial.30 These results are concordant with the results of treatment assignment sensitivity analyses in this trial showing that ablation was associated with improved primary end point and mortality outcomes, providing that the ablation group patients actually received ablative therapy.

    AF Recurrence

    Quiz Ref IDFor most patients with AF, the primary reason to consider catheter ablation is to mitigate the disruption that AF creates in their daily lives and consequent reductions in quality of life. This trial shows that catheter ablation is associated with a lower AF recurrence rate than drug therapy (50% vs 69% at 3 years postblanking follow-up). These results are generally concordant with the findings of earlier smaller trials on AF recurrence such as CASTLE-AF,10 RAAFT-2,31 STOP-AF,7 ThermoCool AF,8 and to a lesser degree MANTRA-PAF.32 The long-term follow-up from this trial also shows that for many patients with AF, ablation is not curative. One hundred and ninety patients (17.1%) required a repeat ablation during the postblanking follow-up period. The underlying pathophysiology leading to the initial onset of AF may increase the propensity for its recurrence even with initially successful ablation. Work is ongoing to understand whether risk factor management, with or without ablation, can reduce recurrence rates.

    Adverse Events

    Importantly, CABANA shows that prognostically adverse procedural complications associated with the catheter ablation strategy relative to medical management options were infrequent when the procedure was performed by experienced operators (eTables 9 and 10 in Supplement 3). Pericardial effusion with tamponade, while infrequent, was the most common adverse event in catheter ablation patients. Pulmonary vein stenosis was rare and atrial esophageal fistula formation was not observed. The adverse event rates observed in the trial are comparable with data from the First and Second International Ablation Registries,4,33,34 and are similar to those seen in the RAAFT-231 and MANTRA-PAF trials,32 but lower than those seen in the STOP-AF trial.7 Whether the rates of catheter ablation–related procedural complications would be the same outside of a clinical trial is unknown and would be an important consideration in discussing treatment options with patients.

    Limitations

    Quiz Ref IDThis study has several limitations. First, patient withdrawals from the trial, which occurred at a slightly higher rate in the drug therapy group, may have affected estimates of the treatment effect. Second, comparisons of the ITT results with the treatment received and per-protocol analyses suggest that the combined effect of crossovers and withdrawals reduced the estimated treatment effect and the precision of the effect size estimates as assessed by ITT. Third, catheter ablation and drug therapies may have changed over the course of a long trial in ways that might have affected outcome, although ablation techniques were largely consistent over the course of the trial, and crossovers were limited by the trial center to the extent possible.

    Fourth, a small number of patients (11%) received only rate control drugs, which could have affected the results. Fifth, the AF recurrence data presented here come from the subset of patients who used the trial’s recording system, but findings were consistent when trial-wide recording systems were compared. Sixth, unblinded site adjudication of cause of hospitalization may have introduced bias into this end point relative to the centrally adjudicated components of the primary end point. Seventh, the significance threshold was not adjusted for the secondary end point comparisons. Performing multiple independent significance tests increases the probability that at least 1 test may achieve nominal statistical significance on a chance basis alone. Therefore, findings from the secondary and other analyses that are unique to CABANA may be reasonably viewed as more provisional or exploratory.

    Conclusions

    Among patients with AF, the strategy of catheter ablation, compared with medical therapy, did not significantly reduce the primary composite end point of death, disabling stroke, serious bleeding, or cardiac arrest. However, the estimated treatment effect of catheter ablation was affected by lower-than-expected event rates and treatment crossovers, which should be considered in interpreting the results of the trial.

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    Article Information

    Corresponding Author: Douglas L. Packer, MD, Mayo Clinic/St Marys, 1216 Second St SW, Al 2-416, Rochester, MN 55902 (packer@mayo.edu).

    Accepted for Publication: February 14, 2019.

    Published Online: March 15, 2019. doi:10.1001/jama.2019.0693

    Author Contributions: Drs Packer and Lee had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Packer, Mark, Robb, Monahan, Bahnson, Poole, Rosenberg, Mitchell, Flaker, Bunch, Wilber, Hindricks, Piccini, Kowey, Naccarelli, Lee.

    Acquisition, analysis, or interpretation of data: Packer, Mark, Monahan, Bahnson, Noseworthy, Jeffries, Mitchell, Flaker, Pokushalov, Romanov, Bunch, Noelker, Ardashev, Revishvili, Wilber, Cappato, Kuck, Hindricks, Davies, Piccini, Kowey, Reiffel, Silverstein, Al-Khalidi, Lee.

    Drafting of the manuscript: Packer, Mark, Monahan, Bahnson, Silverstein, Lee.

    Critical revision of the manuscript for important intellectual content: Packer, Mark, Robb, Monahan, Bahnson, Poole, Noseworthy, Rosenberg, Jeffries, Mitchell, Flaker, Pokushalov, Romanov, Bunch, Noelker, Ardashev, Revishvili, Wilber, Cappato, Kuck, Hindricks, Davies, Piccini, Kowey, Naccarelli, Reiffel, Silverstein, Al-Khalidi, Lee.

    Statistical analysis: Packer, Mark, Jeffries, Silverstein, Al-Khalidi, Lee.

    Obtained funding: Packer, Mark, Robb, Lee.

    Administrative, technical, or material support: Packer, Monahan, Bahnson, Noseworthy, Rosenberg, Mitchell, Bunch, Noelker, Davies, Piccini, Lee.

    Supervision: Packer, Monahan, Rosenberg, Flaker, Romanov, Bunch, Ardashev, Lee.

    Conflict of Interest Disclosures: Dr Packer reported receiving grants from the National Institutes of Health (NIH)/National Heart, Lung, and Blood Institute (NHLBI), St Jude Medical Corporation and Foundation, Biosense Webster Inc, Medtronic Inc, and Boston Scientific Corp during the conduct of the study and receiving grants from Abbott, Biosense Webster Inc, Boston Scientific Corp, CardioFocus, Medtronic Inc, St Jude Medical, CardioInsight, the NIH, Siemens, Thermedical, Endosense, Robertson Foundation, and Hansen Medical; serving on the advisory board without compensation for Abbott, Biosense Webster Inc, Boston Scientific Corp, CardioFocus, Medtronic Inc, St Jude Medical, Spectrum Dynamics, Siemens, Thermedical, Johnson & Johnson, and SigNum Preemptive Healthcare Inc; speaking with honorarium from Biotronik and MediaSphere Medical LLC; and receiving royalties from Wiley & Sons, Oxford, and St Jude Medical. Dr Packer and Mayo Clinic jointly have equity in a privately held company, External Beam Ablation Medical Devices, outside the submitted work. In addition, Dr Packer has mapping technologies with royalties paid. Dr Mark reported receiving grants from the NIH/NHLBI and Mayo Clinic during the conduct of the study and grants from Merck, Oxygen Therapeutics, Bristol-Myers Squibb, AstraZeneca, the University of Calgary, Eli Lilly & Company, AGA Medical, St Jude Medical, and Tufts University and personal fees from CeleCor outside the submitted work. Dr Robb reported receiving grants from the NIH/NHLBI, St Jude Medical Corporation and Foundation, Biosense Webster Inc, Medtronic Inc, and Boston Scientific Corp during the conduct of the study. Dr Robb has a patent for a 4D mapping system with royalties paid to Endocardial Solutions outside the submitted work. Ms Monahan reported receiving grants from the NIH/NHLBI, St Jude Foundation and Corporation, Biosense Webster Inc, Medtronic Inc, and Boston Scientific Corp during the conduct of the study; consulting without compensation from Biosense Webster Inc; and receiving personal fees from Thermedical outside the submitted work. Dr Bahnson reported receiving grants from the NIH/NHLBI and Mayo Clinic during the conduct of the study and grants from St Jude Medical Inc, Abbott Medical, Medtronic Inc, Biosense Webster Inc, Johnson & Johnson, the NIH, and Boston Scientific Corp; and consulting fees from Cardiofocus Inc and Ventrix outside the submitted work. Dr Bahnson has patents pending for a catheter for intracardiac imaging and intracardiac electrogram signal analysis. Dr Poole reported receiving grants from ATriCure outside the submitted work. Dr Noseworthy reported receiving grants from the NHLBI outside the submitted work and being a co–principal investigator in the Pairing Observational and Patient-Level Clinical Trial Data to Assess Cardiovascular Risk Reduction With Catheter Ablation for Atrial Fibrillation study. Dr Mitchell reported receiving expense reimbursement from the NIH during the conduct of the study and personal fees from Bayer, Boehringer-Ingelheim, Bristol-Myers Squibb/Pfizer, Servier, and Medtronic Inc and grants from Population Health Research Institute, Hamilton, Ontario, Canada, outside the submitted work. Dr Flaker reported receiving grants from Daiichi Sankyo and Janssen Pharmaceutical and grants and personal fees from Boehringer-Ingelheim, Bristol-Myers Squibb, and Pfizer outside the submitted work. Dr Bunch reported receiving grants from Boehringer-Ingelheim outside the submitted work. Dr Wilber reported receiving grants and personal fees from Biosense Webster Inc and Medtronic Inc and grants from Abbott and Sentre Heart outside the submitted work. Dr Cappato reported receiving grants from Boston Scientific Corp, Medtronic Inc, Daiichi Sankyo, St Jude Medical, Bayer, and Pfizer. Dr Kuck reported receiving personal fees from Medtronic Inc, Boston Scientific Corp, Abbott, Edwards Lifesciences, and Biosense Webster Inc outside the submitted work. Dr Hindricks reported receiving grants from Abbott and Boston Scientific Corp, directly to Heart Centre Leipzig, during the conduct of the study. Dr Davies reported receiving personal fees from Medtronic Inc outside the submitted work. Dr Kowey reported receiving personal fees from Medtronic Inc and personal fees from and equity interest in Biotelemetry outside the submitted work. Dr Naccarelli reported receiving grants and personal fees from Janssen and personal fees from GlaxoSmithKline, Aceion, Omeicos, Sanofi, and Portola outside the submitted work. Dr Reiffel reported receiving grants and personal fees from Medtronic Inc and personal fees from Gilead, Janssen/Johnson & Johnson, Portola, Acension, InCardia Therapeutics, Roivant, and Sanofi outside the submitted work. Dr Piccini reported receiving grants from ARCA Biopharma, Boston Scientific Corp, Gilead Sciences, Janssen Pharmaceuticals, Abbott, and Verily and consulting fees from Abbott, Allergan, Bayer, Biotronik, Johnson & Johnson, Medtronic Inc, Sanofi, and Philips outside the submitted work. Dr Al-Khalidi reported receiving grants from the NIH/NHLBI and Mayo Clinic during the conduct of the study. Dr Lee reported receiving grants from the NIH/NHLBI, Mayo Clinic, St Jude Medical Foundation and Corporation, Biosense Webster Inc, Medtronic Inc, and Boston Scientific Corp and serving on data and safety monitoring boards on studies funded by AstraZeneca, Medtronic Inc, Merck, Amgen, and the Cardiovascular Research Foundation during the conduct of the study. No other disclosures were reported.

    Funding/Support: This research was funded by awards from the NIH. Dr Packer was supported by NIH grant U01HL089709. Dr Lee was supported by NIH grant U01HL089786. Dr Mark was supported by NIH grant U01HL089907. Dr Robb was supported by NIH grant U01HL089645. This research was also funded by St Jude Medical Foundation and Corporation, Biosense Webster Inc, Medtronic Inc, and Boston Scientific Corp.

    Role of the Funder/Sponsor: The NIH established an independent data and safety monitoring board to monitor safety but had no role in the design of the study; collection, management, and interpretation of the data; preparation of the manuscript; or decision to submit the manuscript for publication. St Jude Medical Foundation and Corporation, Biosense Webster Inc, Medtronic Inc, and Boston Scientific Corp had no role in the design of the study; collection, management, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

    Clinical Site Principal Investigators and Institutions: (Listed in descending order of the number of randomized patients): Evgeny Pokushalov, Alexander Romanov, E. Meshalkin National Medical Research Center of the Ministry of Health of the Russian Federation, Novosibirsk, Russian Federation (147); T. Jared Bunch, Intermountain Medical Center, Murray, Utah (139); Tristram Bahnson, Duke University Medical Center, Durham, North Carolina (133); Georg Noelker, Herz-und Diabeteszentrum NRW, Bad Oeynhausen, Germany (98); Douglas Packer, Mayo Clinic, Rochester, Minnesota (93); Gerhard Hindricks, Herzzentrum Leipzig, Leipzig, Germany (88); Andrey Ardashev, Clinical Hospital No. 83 under the Federal Medical and Biological Agency, Moscow, Russia (66); Amiran Revishvili, George Matsonashvili, Bakoulev Scientific Center for Cardiovascular Surgery, Moscow, Russia (52); Pugazhendhi Vijayaraman, Geisinger Wyoming Valley Medical Center, Wilkes-Barre, Pennsylvania (43); Huseyin Ince, Universitat Rostock, Rostock, Germany (previously Dietmar Baensch) (42); Christopher Piorkowski, Technische Universitat Dresden, Dresden, Germany (41); Thomas Neumann, Kerckhoff Klinik, Bad Nauheim, Germany (40); George Veenhuyzen, University of Calgary, Calgary, Alberta, Canada (39); Anil Gehi, University of North Carolina at Chapel Hill (previously Paul Mounsey) (38); David Wilber, Loyola University Medical Center, Maywood, Illinois (36); Felix Sogade, Georgia Arrhythmia Consultants, Macon (34); Carlo Pappone, Policlinico San Donato Center of Clinical Arrhythmia and Electrophysiology, San Donato Milanese, Italy (previously Riccardo Cappato) (32); Adam Berman, Georgia Regents University, Augusta (31); Alaa Shalaby, V.A. Pittsburgh Healthcare System, Pittsburgh, Pennsylvania (25); Karl-Heinz Kuck, Asklepios Klinik Saint George, Hamburg, Germany (25); Blair Halperin, Providence Saint Vincent Medical Center, Portland, Oregon (25); Venkat Tholakanahalli, Minneapolis V.A. Medical Center, Minneapolis, Minnesota (24); Eugen Palma, Montefiore Medical Center, New York, New York (24); John Holshouser, The Sanger Clinic, PA, Charlotte, North Carolina (24); Nitish Badhwar, University of California at San Francisco Medical Center (23); Haroon Rashid, Virginia Hospital Center–Arlington (23); Craig Cameron, Oklahoma Heart Institute, Tulsa (22); John Hummel, The Ohio State University Medical Center, Columbus (22); Pablo Saavedra, Vanderbilt University Medical Center, Nashville, Tennessee (previously Dawood Darbar) (21); J. Brian Deville, The Heart Hospital Baylor Plano, Plano, Texas (21); Julian Chun, Cardioaniologisches Centrum Bethanien, Frankfurt, Germany (20); Javier Roman-Gonzalez, South Texas Cardiovascular Consultants, San Antonio (20); Stephen Willems, Universitares Herzzentrum Hamburg, Hamburg, Germany (20); Hasan Garan, Columbia University Medical Center, New York, New York (20); Eric Michael Crespo, Hartford Hospital, Hartford, Connecticut (19); Peter Cheung, Scott and White Memorial Hospital, Temple, Texas (previously David Fitzgerald) (18); Gerian Groenefeld, Asklepios Klinik Barmbek, Hamburg, Germany (17); Claudio Schuger, Henry Ford Hospital, Detroit, Michigan (16); Tariq Salam, Cardiac Study Center, Tacoma, Washington (16); Yanzong Yang, The First Affiliated Hospital of Dalian Medical University, Dalian, China (15); Carlo Pappone, Maria Cecilia Hospital, Cotignola, Italy (15); Dan Wichterle, Charles University, Prague 2, Czech Republic (15); Johannes Brachmann, Klinikum Coburg, Coburg, Germany (15); Josef Kautzner, Clinic of Cardiology IKEM Medical Institute, Prague 4, Czech Republic (15); John Jayachandran, Baylor All Saints Medical Center, Fort Worth, Texas (15); Young-Hoon Kim, Korea University Anam Hospital, Seoul, Korea (14); Christopher Cole, Penrose Saint Francis Health Services, Colorado Springs, Colorado (14); Bengt Herweg, University of South Florida, Tampa (13); Martin Lowe, The Heart Hospital, London, United Kingdom (12); Anne Dougherty, University of Texas Health Science Center at Houston (previously Bharat Kantharia and Nada Memon) (12); Sergey Popov, Scientific Research Institute of Cardiology of Siberian Dept of Russian Academy of Medical Sciences, Tomsk, Russia (11); Martin Lowe, Saint Bartholomew’s Hospital, London, United Kingdom (previously Richard Schilling) (11); Stefan Spitzer, Praxisklinik Herz and GefaBe, Dresden, Germany (11); Robert Bernstein, Sentara Norfolk General Hospital, Norfolk, Virginia (11); Jay Simonson, Park Nicollet Heart and Vascular Center/Methodist Hospital, St Louis Park, Minnesota (11); Eric Buch, University of California Los Angeles (10); Shulin Wu, Guangdong Provincial People’s Hospital, Guangzhou, China (10); Mohammed Khan, Alexian Brothers Medical Center, Elk Grove Village, Illinois (10); Timothy Shinn, Saint Joseph Mercy Hospital, Ann Arbor, Michigan (previously James Kappler) (10); Petr Neuzil, Na Homolce Hospital, Prague, Czech Republic (9); James Mangrum, University of Virginia Health System, Charlottesville (9); Hugh Calkins, Johns Hopkins Hospital, Baltimore, Maryland (9); Mario Gonzalez, Penn State University Cardiovascular Center, Hershey, Pennsylvania (9); Moussa Mansour, Massachusetts General Hospital, Boston (9); Markus Zabel, Georg-August-University, Goettingen, Germany (8); Jonathan Kalman, Royal Melbourne Hospital, Parkville, Australia (8); Jose Sanchez, Saint John’s Mercy Heart Hospital, St Louis, Missouri (8); Steven Rothman, Lankenau Medical Center, Wynnewood, Pennsylvania (8); Anil Bhandari, Good Samaritan Hospital, Los Angeles, California (8); Cynthia Tracy, George Washington University Medical Center, Washington, DC (8); Raul Mitrani, University of Miami Health System, Miami, Florida (7); Vicken Vorperian, Waukesha Memorial Hospital, Waukesha, Wisconsin (7); Derek Connelly, Golden Jubilee Hospital, Glasgow, United Kingdom (7); Darryl Wells, Swedish Medical Center–Providence Campus, Seattle, Washington (7); Chang-Sheng Ma, Beijing Anzhen Hospital, Beijing, China (7); Atul Verma, Southlake Regional Health Centre, Newmarket, Ontario, Canada (7); S. Luke Kusmirek, Drexel University College of Medicine, Philadelphia, Pennsylvania (7); Melissa Robinson, University of Washington Medical Center, Seattle (previously Robert Rho and Mohan Viswanathan) (7); Donald Rubenstein, Greenville Hospital System University Medical Center, Greenville, South Carolina (6); Emilio Vanoli, Policlinico Multimedical Cardiology and Arrhythmia Centre, Milan, Italy (previously Annibale Montenero) (6); Shu Zhang, Fuwai Hospital, Beijing, China (6); Jennifer Cummings, The University of Toledo, Toledo, Ohio (previously Mohammed Kanjwal) (6); Mohan Viswanathan, Stanford University Medical Center, Stanford, California (previously Amin Al Ahmad and Paul Zei) (6); George Monir, Florida Hospital, Orlando (6); Francis Marchlinski, University of Pennsylvania Health System, Philadelphia (6); Jay Franklin, Baylor Heart and Vascular Hospital, Dallas, Texas (previously Robert Kowal) (6); Bruce Koplan, Brigham and Women’s Hospital, Boston, Massachusetts (previously Gregory Michaud) (6); Prashanthan Sanders, Royal Adelaide Hospital, Adelaide, South Australia, Australia (5); Eric Rashba, Stony Brook University Medical Center, Stony Brook, New York (5); Mark Gallagher, Saint George’s Hospital Medical School, London, United Kingdom (5); Bernd Gonska, Saint Vincentius-Kliniken, Karlsruhe, Germany (5); Minglong Chen, First Affiliated Hospital of Nanjing Medical University, Nanjing, China (5); Peter Leong-Sit, University of Western Ontario–London Health Sciences Centre, London, Ontario, Canada (5); John Zimmerman, Hackensack University Medical Center, Hackensack, New Jersey (5); Nayer Pezeshkian, University of California Davis Medical Center, Sacramento (5); Andrew Cohen, The Medical Center of Aurora, Aurora, Colorado (5); Saulius Kalvaitis, Saint Louis Heart and Vascular, St Louis, Missouri (4); David Davies, Saint Mary’s Hospital, London, United Kingdom (4); Martin Borggrefe, University Hospital of Mannheim, Mannheim, Germany (4); Hui-Nam Pak, Yonsei University Severance Hospital, Seoul, Korea (4); Andrea Russo, Cooper University Hospital, Camden, New Jersey (4); Charles Henrikson, Oregon Health and Science University, Portland (previously Jack Kron) (4); Gerald Greer, Arkansas Cardiology, PA, Little Rock (4); James Coromilas, Robert Wood Johnson University Hospital, New Brunswick, New Jersey (3); Farhat Khairallah, Tallahassee Memorial Hospital, Tallahassee, Florida (3); Guillermo Sosa-Suarez, Albany Associates in Cardiology, Albany, New York (3); Bruce Lindsay, Cleveland Clinic Foundation, Cleveland, Ohio (3); Westby Fisher, North Shore University Health System/Evanston Hospital, Evanston, Illinois (3); Steven Bailin, Mercy Medical Center, Des Moines, Iowa (3); Andy Tran, Scottsdale Healthcare, Scottsdale, Arizona (2); Zdenek Starek, Saint Anne’s University Hospital, ICRC, Brno, Czech Republic (2); Mark Preminger, The Valley Hospital, Ridgewood, New Jersey (2); Robert Sheppard, Northside Hospital and Heart Institute, St Petersburg, Florida (2); Alexandru Costea, University of Cincinnati Medical Center, Cincinnati, Ohio (2); Kenneth Ellenbogen, Virginia Commonwealth University Medical Center, Richmond (2); Thomas Arentz, Herz-Zentrum Bad Krozingen, Bad Krozingen, Germany (1); Roberto De Ponti, Ospedale di Circolo e Fondazione Macchi, Varese, Italy (1); Ryan Aleong, University of Colorado Hospital, Aurora (1); Byron Colley III, Jackson Heart Clinic, Jackson, Mississippi (1); Khawaja Baig, Medisync, Cincinnati, Ohio (1); Kousik Krishnan, Rush University Medical Center, Chicago, Illinois (1); Syamkumar Divakara Menon, Hamilton Health Sciences, Hamilton, Ontario, Canada (previously Carlos Morillo) (1); Tony Simmons, Wake Forest University Health Sciences, Winston-Salem, North Carolina (1); Gregory Bruce, Memorial Health Care System, Chattanooga, Tennessee (1); Larry Chinitz, Tisch Hospital (New York University Langone Medical Center), New York (1); Andrea Natale, Texas Cardiac Arrhythmia, Austin (1); and Riccardo Cappato, IRCCS Istituto Clinico Humanitas, Milano, Italy.

    Disclaimer: The content of this article does not necessarily represent the views of the NHLBI or the Department of Health and Human Services.

    Meeting Presentation: This study was presented at the Annual Heart Rhythm Society Scientific Sessions; May 10, 2018; Boston, Massachusetts.

    Data Sharing Statement: See Supplement 4.

    Additional Contributions: We are grateful to all patients and their families for their participation in this study, the study sites, and the study monitors. Editorial assistance with preparation of the manuscript was provided by Jacqueline Crowson, Mayo Clinic, Rochester, Minnesota, without personal compensation. Statistical and data coordinating center project leadership was provided by Beth Martinez, MS, PMP, Durham, North Carolina, without personal compensation.

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