Editorial

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

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MORE STUDIES UNDER WAY

Two other initiatives may help define the role of ablation for atrial fibrillation.

The Cardiac Ablation vs Antiarrhythmic Drug Therapy for Atrial Fibrillation (the CABANA) trial is a multicenter randomized longitudinal study designed to determine whether ablation is more effective than drug therapy. Target enrollment is 3,000 patients.

The National Cardiovascular Data Registry is exploring the possibility of establishing a registry for ablation of atrial fibrillation. This database could be used by physicians, hospitals, the Centers for Medicare & Medicaid Services, and the US Food and Drug Administration to track overall outcomes of these complex procedures.

FOR NOW, DRUGS ARE STILL THE FIRST-LINE TREATMENT

For now, I believe that antiarrhythmic drugs should remain the first line of treatment for atrial fibrillation until cumulative evidence from additional randomized multicenter trials proves otherwise. However, the threshold for deciding to do an ablation procedure is getting lower, and it is reasonable for patients to make an informed decision to move directly to ablation as an alternative to drug therapy if that is their preference.

To make these decisions, patients need accurate information about success rates and the risk of complications at the center where the procedure is to be performed. At Cleveland Clinic, where more than 4,300 ablation procedures have been performed for atrial fibrillation, substantial resources are devoted to tracking outcomes. As the government and insurance companies focus on pay for performance and as ablation procedures for atrial fibrillation become more widespread and new technologies are introduced, it will be especially important for hospitals to track their own costs and outcomes.

The cumulative experience from well-designed clinical trials will provide guidance, but unless hospitals verify that they achieve results equivalent to those in the trials, physicians should be cautious about recommending ablation as the first-line therapy.

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