Should catheter ablation be the first line of treatment for atrial fibrillation?

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Catheter ablation for atrial fibrillation has evolved since it was introduced a decade ago. It will continue to improve as we gain experience with the procedure, better understand the pathophysiology of atrial fibrillation, and develop new technologies for imaging, catheter navigation, and more effective ablation of atrial tissue. The topic is reviewed by Chowdhury et al1 in this issue of the Cleveland Clinic Journal of Medicine.

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An important question is whether catheter ablation should replace antiarrhythmic drugs as the first line of therapy. The answer will be determined by the procedure’s success rate, complication rate, cost, and long-term outcomes compared with drug therapy.


Relatively few randomized trials have compared catheter ablation and medical therapy.

In patients with paroxysmal atrial fibrillation, three important randomized trials2–4 have shown catheter ablation to be superior to antiarrhythmic drug therapy. In these trials, freedom from atrial fibrillation or atrial flutter was achieved in 63% to 93% of patients who underwent ablation compared with 17% to 35% of those assigned to drug therapy. However, more than one ablation procedure may be required to achieve success rates in the higher range. Further, these studies were done at “high-volume” centers, and they excluded patients with major comorbidities.

Persistent or long-standing atrial fibrillation is more complex than paroxysmal atrial fibrillation. It is more often accompanied by significant comorbidities, and comparative trials have generally excluded patients with these attributes. Fewer of such patients obtain complete success (ie, cure), and more of them need a second ablation procedure.

Oral et al5 randomly assigned patients with long-standing atrial fibrillation to be treated with amiodarone (Cordarone) or catheter ablation. The analysis of this study was complicated by a high rate of crossover from the drug therapy group to the ablation group. Twenty-five (32%) of the 77 patients assigned to undergo ablation needed a second procedure, but at 12 months 74% were in sinus rhythm without amiodarone, compared with only 4% treated with amiodarone without ablation.

These results indicate that ablation is more effective than medical therapy for paroxysmal atrial fibrillation, and it appears to be more effective than drugs alone for long-standing persistent atrial fibrillation. In addition, quality of life was better after ablation, and complications were relatively few.2–4

The limitations are that the trials were done at hospitals in which the ablation teams had a lot of experience, did many ablation procedures per year, and tracked their outcomes carefully: other hospitals may not be able to achieve the same results. Moreover, many patients referred for ablation have heart failure, significant valvular disease, or left atrial enlargement, which would have excluded them from the published trials.

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