Pulsed Field Ablation (PFA) vs Anti-Arrhythmic Drug (AAD) Therapy as a First Line Treatment for Persistent Atrial Fibrillation (AVANTGUARD)

Boston Scientific

Status: Enrolling

Conditions: Persistent Atrial Fibrillation

Treatments: Device: FARAPULSE™ Pulsed Field Ablation (PFA) System; Drug: Anti-Arrhythmic Drug (AAD): Flecainide, Sotalol, Propafenone, Dofetilide, and Dronedarone

Study type: Interventional

Funder types: Industry

Identifiers

NCT06096337

PF303

Details and patient eligibility

About

The purpose of this study is to establish the safety and effectiveness of pulsed field ablation as a first-line ablation treatment for subjects with persistent atrial fibrillation as compared to subjects who received an initial treatment with anti-arrhythmic drugs.

Full description

This is a prospective, randomized, multi-center, global, pivotal Investigational device exemption (IDE) study. Subjects with persistent atrial fibrillation will be randomized or assigned to either pulsed field ablation (PFA) or Versus Anti-Arrhythmic Drug (AAD) treatment.

Once randomization is complete, additional subjects will be enrolled and sequentially assigned to receive PFA treatment to fulfill the number of subjects required for the Primary Safety Endpoint assessment. These additional subjects are referred to as PFA Assigned (Non-Roll-In) Subjects.

Subjects randomized or assigned to PFA treatment will undergo percutaneous ablative pulmonary vein isolation (PVI) and left atrial posterior wall isolation (PWI) using the FARAWAVE™ PFA Catheter (first-line ablation cohort).

Subjects randomized to AAD treatment will be prescribed and monitored in accordance with local clinical practice and already established guideline-directed therapy for patients with persistent atrial fibrillation (AF). In the case of clinical inefficacy, the AAD dose will be up-titrated to the maximum tolerated dose. Thereafter, a change to a second or to a third AAD should be undertaken, insofar as the subject remains within the blanking period, with the goal to completely suppress AF episodes ≥ 30 seconds in duration. If AAD treatment is proven to be ineffective or intolerable outside of the blanking period, subjects can undergo subsequent ablation therapy and be considered part of the "delayed ablation cohort".

Enrollment: 520 estimated patients

Sex: All

Ages: 18+ years old

Volunteers: No Healthy Volunteers

Inclusion criteria

• 1. Age ≥ 18 years of age, or older if specified by local law
• 2. Have symptomatic persistent AF, confirmed by both:

  a. Documentation, within 180 days of randomization, or treatment assignment for roll-in subjects, of either:

• i. A 24-hour continuous ECG recording (from any regulatory cleared rhythm monitoring device) confirming continuous AF, OR

• ii. Two ECGs (from any regulatory cleared rhythm monitoring device) showing continuous AF taken at least 7 days apart b. Documentation, such as physician note, of persistent continuous AF for > 7 days and ≤ 365 days

• 3. Willing and capable of providing informed consent
• 4. Willing and capable of participating in all testing associated with this clinical investigation at an approved clinical investigational center
• 5. Willing to receive LUX-Dx™ insertable cardiac monitor (ICM) during the study or already has a LUX-Dx™ ICM that was inserted ≤ 6 months(i.e., within 180 days of consent

Exclusion criteria

• 1. Treated with AAD (Class I or III) ≤ 6 months (i.e., within 180 days) before enrollment,

  a. More than 7-day history of therapeutic AAD use (Class I or III), orb. ≥ 24 hours amiodarone, i Note Pill-in-the-pocket AAD use, is permitted. 2. Treated with AAD ( Class I or III) > 6 months (i.e., more than 180 days) before enrollment and experienced AAD failure (adverse drug effects or frequent AF episodes) 3. Contraindication to, or unwillingness to use, AADs (Class I and III, excluding amiodarone) 4. Contraindication to PFA treatment 5. Contraindication to, or unwillingness to use, systemic anticoagulation, or acceptable alternatives, pre-, intra-, and post-procedure to achieve adequate anticoagulation.

  6. Any of the following atrial conditions:
  7. Left atrial (LA) anteroposterior diameter ≥ 5.5 cm, or, if LA diameter not available, non-indexed volume >100 ml, as documented by physician note or imaging (Note: if both values are available, only the LA diameter will be used to confirm eligibility criteria)
  8. Any prior atrial endocardial, epicardial or surgical ablation procedure for arrhythmia, other than right sided cavotricuspid isthmus ablation or for right sided supraventricular tachycardia
  9. Current atrial myxoma
  10. Any PV abnormality, stenosis, or stenting (common and middle PVs are admissible)
  11. Current left atrial thrombus

• 7. Any of the following cardiovascular conditions:

  8. History of sustained ventricular tachycardia or any ventricular fibrillation

  9. AF that is secondary to electrolyte imbalance, thyroid disease, alcohol, or other reversible / non-cardiac causes

  10. Current or anticipated pacemaker, implantable cardioverter defibrillator or cardiac resynchronization therapy devices, interatrial baffle, atrial septal patch, atrial septal defect closure device, or patent foramen ovale occluder

  11. Valvular disease that is any of the following: i. Symptomatic, ii. Causing or exacerbating congestive heart failure, iii. Associated with abnormal left ventricular (LV) function or hemodynamic measurements

  12. Hypertrophic cardiomyopathy

  13. Cardiac amyloidosis

  14. Any prosthetic heart valve, ring or repair including balloon aortic valvuloplasty

  15. Any inferior vena cava (IVC) filter, known inability to obtain vascular access or other contraindication to femoral access

  16. Rheumatic heart disease

  17. Congenital heart disease with any clinically significant residual anatomic or conduction abnormality

  18. Awaiting cardiac transplantation or other cardiac surgery within the next 12 months

• 8. Any of the following conditions identified during screening assessments

  9. Heart failure associated with New York Heart Association (NYHA) Class IV

  10. Left Ventricle Ejection Fraction (LVEF) < 40%

  11. Uncontrolled hypertension (Systolic Blood Pressure > 160 mmHg or Diastolic Blood Pressure > 95 mmHg on two (2) BP measurements during screening

• 9. Any of the following events 90 days prior to randomization (or Index procedure for PFA Assigned or roll-in subjects):

  10. Myocardial infarction (MI), unstable angina or coronary intervention

  11. Cardiac surgery

  12. Heart failure hospitalization

  13. Pericarditis or symptomatic pericardial effusion

  14. Gastrointestinal bleeding

  15. Stroke, TIA, or intracranial bleeding

  16. Non-neurologic thromboembolic event

  17. Carotid stenting or endarterectomy

• 10.Known coagulopathy disorder (e.g., von Willbrand's disease, hemophilia)

• 11. Unwillingness to receive, or unable to tolerate, a subcutaneous, chronically inserted LUX-Dx™ ICM device
• 12. Women of childbearing potential who are pregnant, lactating, not using a reliable form of contraception, or who are planning to become pregnant during the anticipated study period
• 13. Body Mass Index (BMI) > 45
• 14. Solid organ or hematologic transplant, or currently being evaluated for a transplant
• 15. Any prior history or current evidence of hemi-diaphragmatic paralysis or paresis
• 16. Severe lung disease, or any lung disease involving abnormal blood gases or requiring supplemental oxygen
• 17. Severe pulmonary hypertension during screening assessment
• 18. Renal insufficiency if an estimated glomerular filtration rate (eGFR) is < 30 mL / min / 1.73 m2, or with any history of renal dialysis or renal transplant
• 19. Active malignancy at enrollment (other than cutaneous basal cell or squamous cell carcinoma)
• 20. Clinically significant gastrointestinal problems involving the esophagus or stomach including severe or erosive esophagitis, uncontrolled gastric reflux, gastroparesis, esophageal candidiasis or active gastroduodenal ulceration
• 21. Known active systemic infection
• 22. Uncontrolled diabetes mellitus or a recorded HgbA1c > 8.0% in the 90 days prior to randomization (or Index procedure for PFA Assigned or roll-in subjects)
• 23. Untreated diagnosed obstructive sleep apnea with apnea hypopnea index classification of severe (>30 pauses per hour)
• 24. Predicted life expectancy less than one (1) year
• 25. Currently enrolled in another investigational study or registry that would directly interfere with this study, except when the subject is participating in a mandatory governmental registry, or a purely observational registry with no associated treatments; each instance must be brought to the attention of the Sponsor to determine eligibility
• 26. Health conditions that, in the investigator's medical opinion, would prevent participation in the study, interfere with assessment or therapy, significantly raise the risk of study participation, or modify outcome data or its interpretation
• 27. Has operational LUX-Dx ICM that was inserted more than 6 months (i.e., >180 days) prior to enrollment
• 28. Has operational ICM other than a LUX-Dx ICM and does not express a willingness to receive a LUX-Dx ICM for the study
• 29. Individuals who may require an ablation, besides the PV and PW, in the left atrium including, but not limited to, those with Left-Sided Atrioventricular Reentrant Tachycardia (AVRT), Left-Sided Atrial Tachycardia (AT), or Atypical Left-Sided Atrial Flutter.

Trial design

Primary purpose: Treatment

Allocation: Randomized

Interventional model: Parallel Assignment

Masking: None (Open label)

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520 participants in 2 patient groups

Pulsed Field Ablation (PFA)

Experimental group

Description:

Pulsed Field Ablation (PFA) is used as the initial treatment for subjects with persistent atrial fibrillation (AF)

Treatment:

Device: FARAPULSE™ Pulsed Field Ablation (PFA) System

Anti-Arrhythmic Drug (AAD)

Active Comparator group

Description:

Anti-Arrhythmic Drug (AAD) is used as the initial treatment for subjects with persistent atrial fibrillation (AF)

Treatment:

Drug: Anti-Arrhythmic Drug (AAD): Flecainide, Sotalol, Propafenone, Dofetilide, and Dronedarone