Can We Consider Catheter Ablation
as First-Line Therapy for all Our Atrial Fibrillation Patients Yet?
Roberto
Matia, Antonio Hernandez Madrid, Giuseppe Lumia
Roberto
Matia, Department of Cardiology, Ramón y
Cajal Hospital, Madrid, Spain
Antonio
Hernandez Madrid, Giuseppe Lumia, Antonio
Hernandez Madrid, Calle Andres Mellado, 96, 28003 Madrid, Spain
Correspondence to: Antonio Hernandez Madrid,
Associate Professor, Calle Andres
Mellado, 96, 28003 Madrid, Spain
Email: antoniomadri@gmail.com
Telephone:+34-609412155
Received: February 4, 2014
Revised: March 24, 2014
Accepted: April 2, 2014
Published online: May 10, 2014
ABSTRACT
The prevalence of atrial fibrillation is increasing. Despite the well
known prognostic benefits of maintaining sinus rhythm, pharmacological
strategies have not provided satisfactory results showing limited efficacy,
proarrhythmic effects, systemic toxicity and in some studies even increased
mortality. AF ablation has undergone a great evolution with an increasing
number of procedures performed all over the world. AF ablation is currently a
topic of intense research. The results of recent research have raised catheter
ablation indication as first-line therapy in patients with symptomatic
paroxysmal AF in the 2012 focused update of the European Society of Cardiology
guidelines. Although much effort remains to be done, we believe that technical
evolution and the increasing expertise of teams performing ablation are
allowing us to treat our patients with safer and more effective procedures. That
is why AF ablation as first-line therapy is here to stay and probably we will
be witness of a further extension of the indications.
© 2014 ACT. All
rights reserved.
Key words: Atrial
fibrillation; Catheter ablation
Matia R, Madrid AH, Lumia G. Can We Consider Catheter Ablation as First-Line
Therapy for all Our Atrial Fibrillation Patients Yet? Journal of Cardiology
and Therapy 2014; 1(4): 80-83 Available from: URL:
http://www.ghrnet.org/index.php/jct/article/view/673
EDITORIAL
Epidemiological
studies show that the prevalence of atrial fibrillation (AF) is increasing[1].
Despite the well known prognostic benefits of maintaining sinus rhythm,
pharmacological strategies have not provided satisfactory results showing
limited efficacy, proarrhythmic effects, systemic toxicity and in some studies
even increased mortality[2].
AF ablation has undergone a
great evolution with an increasing number of procedures performed all over the
world. Since its initial description in 1998, pulmonary vein ablation has been
the cornerstone of AF ablation, specially for paroxysmal cases (Figure 1)[3].
In the last decade multiple randomized trials comparing treatment with catheter
ablation with antiarrhythmic therapy have been published. Most of these studies
have been conducted in patients with paroxysmal AF refractory to one or more
antiarrhythmic drugs (AADs) and have shown that ablation is more effective than
antiarrhythmic therapy in the prevention of recurrences with follow-up periods
between 9 and 12 months. These trials showed 56-89% success rates with ablative
intervention versus 7-23% success rates in those treated with drug therapy
(table 1)[4-8].
Although with less evidence,
we have data from randomized trials also showing greater efficacy in patients
with persistent and long-lasting AF refractory to antiarrhythmic therapy[9,10].
The SARA study is the first multicenter, randomized study that compared
antiarrhythmic therapy with catheter ablation in patients with persistent AF of
less than one year, refractory to at least one class I or class III
antiarrhythmyc drug. After a follow-up period of 12 months, significantly fewer
patients in the ablation group had recurrence of AF ablation or atrial flutter
lasting more than 24 hours or need of cardioversion[9].
Several meta-analysis have
shown the superiority of ablation over antiarrhythmic therapy in the prevention
of AF recurrences[11,12]. Data from randomized trials designed to
address hard clinical outcomes such as stroke, heart failure or mortality are
currently lacking and symptoms-control is nowadays the only well established
rationale to perform AF ablation. However several registries have suggested a
beneficial effect on the incidence of embolic events and mortality[13,14].
The currently ongoing CABANA trial has been designed to test the hypothesis
that AF ablation is superior to drug therapy for decreasing the incidence of
the composite endpoint of total mortality, disabling stroke, serious bleeding
or cardiac arrest (ClinicalTrials.gov: NCT00911508).
Regarding AF ablation as
first-line therapy, Wazni OM et al first published in 2005 a prospective
multicenter randomized study of 70 patients comparing ablation vs
antiarrhythmic therapy for symptomatic AF patients who had not received
previous antiarrhythmic treatment. At one year follow-up, 63% of patients in
the antiarrhythmic group compared to 13% undergoing ablation had an episode of
AF (p<0.01)[15]. New evidence in therapy-naive patients
has been recently added[11,12]. In 2012 Cosedis NJ et al
published a multicenter, randomized study comparing AF ablation as first-line
therapy with antiarrhythmic therapy in 294 patients with a history of
paroxysmal AF who were followed during 2 years. Follow-up included 7-days
Holter monitor recording at 3,6,12,18 and 24 month. In patients randomized to
ablation, circumferential pulmonary vein ablation was performed with a
supplementary linear ablation placed along the roof of the left atrium between
the two encircled areas. At the end of follow-up, the probability of remaining
free of AF (85 vs 71 %, p=0.004) and symptomatic AF (93 vs
84 %, p=0.01) and quality of life were significantly higher in the
ablation group. However, the cumulative burden of AF, which was the primary
endpoint of the study, was not significantly different between the two
treatment groups (13 % vs 19 %, p=0.1)[16]. In the
RAAFT 2 study, which included 127 patients with a history of paroxysmal or
persistent AF not previously treated with AADs, a significant decrease in time
to first AF in patients treated with pulmonary vein isolation was observed (54 vs
72 %, p=0.01). This trial still awaits peer-reviewed publication[17].
The results of these studies
raised catheter ablation indication as first-line therapy in patients with
symptomatic paroxysmal AF in the 2012 focused update of the European Society of
Cardiology guidelines for the management of AF to a IIa indication (level of
evidence B)[18] from a IIb indication (level of evidence B) in the
previous european guidelinse published in 2010[19]. Previous to
aforementioned works[16,17], current guidelines on the management of
patients with AF of the American Heart Association provides no indication of
ablation as first-line treatment[20].
European guidelines states
that AF ablation as first-line treatment should be considered in selected
patients with highly symptomatic paroxysmal AF provided it is performed in
experienced centers and taking into account patient preference who must be adequately
informed about the efficacy and safety of the different available treatment
options[18].
In addition to that stated
in guidelines, other clinical characteristics can help us in the selection of
these patients. In cases with frequent paroxysms of AF, we can offer higher
success rates with a procedure aimed to the ablation of frequent activity
atrial ectopic foci, in addition to electrical isolation of the pulmonary
veins, especially if these foci were shown to trigger AF. The same happens when
paroxysmal supraventricular tachycardia is suspected to cause AF. AF ablation
is also the therapy of choice in order to maintain sinus rhythm in patients who
present contraindications for antiarrhythmic therapy due to sinus bradycardia,
conduction disturbances or channelopaties. Approximately 20% of patients with
Brugada ECG pattern present AF. Yamada et al[21] described
the utility of an AF ablation strategy without any antiarrhythmic drug in 6
patients with Brugada Syndrome and highly symptomatic AF. It should be consider
that patients receiving ablation as first-line therapy must be well informed,
motivated and not unwilling to undergo re-ablation procedures because data have
shown a high incidence of recurrence in the medium term (4-5 years) after
ablation and we know reablation improves efficacy[22].
On the other hand AF
ablation is still a complex intervention and probably highly dependent on the
experience of the team performing the procedure. Real world data shows less
favourable results than those published in randomized trials. The Atrial
Fibrillation Ablation Pilot Study, conducted by the European Heart Rhythm
Association, enrolled 1,410 patients undergoing AF ablation in 72 cardiology
centres in 10 european countries. After one year follow up, 41% of patients
were freedom from AF recurrence without AADs. The complication rate was 7%,
with a major complication rate of 1.7%[23].
AF ablation is currently a
topic of intense research and some of them are providing encouraging results
regarding the identification of the areas involved in AF maintenance in
individual cases, opening the door to more targeted ablation strategies[24].
New technical developments have also emerged to facilitate procedures as
cryoablation, laser ablation, circular ablation catheters and evolved
electroanatomic mapping systems. The key to be able to offer catheter ablation
to an increasing number of patients is to achieve an adequate combination of
good clinical results and low complication rates. Although much effort remains
to be done, we believe that technical evolution and the increasing expertise of
teams performing ablation are allowing us to treat our patients with safer and
more effective procedures. That is why AF ablation as first-line therapy is
here to stay and probably we will be witness of a further extension of the
indications, for instance to selected asymptomatic patients, as already
happened in other arrhythmic substrates.
CONFLICT
OF INTERESTS
There are no
conflicts of interest with regard to the present study.
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