Ablation of atrial fibrillation: What can we tell our patients?
ABSTRACTAlthough catheter-based radiofrequency ablation is no longer experimental, it is not yet the first-line treatment for most patients. The authors describe how this procedure works, its indications, benefits, and limitations, and important points to communicate to potential candidates for this procedure.
KEY POINTS
- During the procedure, scar tissue is created in rings around the ostia of the pulmonary veins and in other locations in the left atrium to electrically isolate triggers of fibrillation and areas that maintain it.
- Results of the procedure are superior to those of drug therapy. Success rates are higher for those with paroxysmal atrial fibrillation than for those with persistent atrial fibrillation.
- The main indication for this procedure is failure of drug therapy or inability to tolerate drug therapy.
- Patients must understand that ablation therapy will not eliminate the need to take anticoagulant drugs.
Arrhythmias
After ablation, new atrial arrhythmias such as atrial flutter are common, with a wide range of reported incidence rates.39 Most cases respond poorly to antiarrythmic drugs, but temporizing measures are recommended, since about half will resolve spontaneously. For this reason, experts generally recommend waiting 2 to 3 months after an ablation procedure before performing a repeat ablative procedure.1,12 Close monitoring is recommended during the months following catheter ablation.
COST AND QUALITY OF LIFE
The cost of catheter ablation needs to be taken into account when considering the procedure for an individual patient.
Catheter ablation is expensive, but so is ongoing medical treatment. In the United States, catheter ablation costs between $17,000 and $21,000 initially, with an ongoing cost of $1,500 to $2,000 per year.3 In comparison, medical therapy costs $4,000 to $5,000 per year. Therefore, catheter ablation would take 4 to 8 years to pay for itself.2
Quality of life also remains a key factor in determining whether to pursue this treatment option. Initial studies showed a trend toward better quality of life with catheter ablation than with medical therapy. In a nonrandomized study published in 2003, Pappone et al40 assessed quality of life in 109 patients who underwent ablation and in 102 medically treated patients, using the 36-item Short-Form General Health Survey. At baseline, both groups similarly rated their quality of life significantly lower than people of the same age and sex in the general population (P < .001). By 6 months, quality-of-life scores in the ablation group had risen to the same level as in the general population, while they stayed the same in the medically treated group. However, data are still limited, and, like the cost of the procedure, estimated quality of life needs to be weighed for the individual patient.
FUTURE DEVELOPMENTS
There are exciting developments in imaging and catheter systems for ablation of atrial fibrillation. It is hoped that these new technologies will improve success rates and reduce complication rates.
In imaging, digital fusion of CT and MRI with electroanatomic mapping shows the anatomy of the junction of the left atrium and pulmonary vein in real time. (Currently, CT and MRI have to be done prior to ablative techniques.)
New ablation systems are being developed that use extreme cold, lasers, and ultrasound. An advantage of these new ablation systems is that they have balloon-tipped catheters, which are placed near the pulmonary vein ostium to deliver full circumferential ablation.41,42
