Ablation Advantageous for Refractory Paroxysmal AF
Major Finding: At 9 months, 66% of paroxysmal atrial fibrillation patients who received radiofrequency catheter ablation were free of treatment failure vs. 16% of patients who received drug therapy.
Data Source: A randomized, multicenter trial of 167 patients with symptomatic paroxysmal atrial fibrillation who did not respond to drug treatment.
Disclosures: Funding and ablation catheters provided by Biosense Webster. Dr. Wilber and several of the coinvestigators reported having financial ties to Biosense Webster and other device makers.
In patients with paroxysmal atrial fibrillation that fails to respond to the first course of drug therapy, radiofrequency catheter ablation is superior to a different antiarrhythmic agent, according to a prospective, multicenter study.
The procedure was better than antiarrhythmic drug treatment, reducing the risk of recurrent arrhythmia and producing clinically meaningful improvements in symptoms and quality of life, said Dr. David J. Wilber of Loyola University, Maywood, Ill., and his associates.
Several studies have compared catheter ablation with drug therapy, but in small populations at a single or a few medical centers.
In their study, Dr. Wilber and his colleagues assessed 167 patients at 19 centers in the United States, Europe, Canada, and Latin America. The patients had not responded to one medication for frequently symptomatic atrial fibrillation and had not received other treatments. After randomization, 106 patients were assigned to undergo catheter ablation and 61 were given a different antiarrhythmic agent (including dofetilide, flecainide, propafenone, sotalol, or quinidine).
The patients were followed for about 1 year. The trial was halted when an interim analysis showed the clear superiority of catheter ablation, with 66% of that group showing an early treatment response that persisted during follow-up vs. 16% of the drug therapy group.
By the end of the trial, “70% of patients treated by catheter ablation remained free of symptomatic recurrent atrial arrhythmia vs. 19% of patients treated with drug therapy,” the researchers said (JAMA 2010;303:333–40). Of the 47 patients who failed to respond to the second course of drug therapy, 36 subsequently underwent ablation.
Major treatment-related adverse events occurred in five patients (4.9%) in the ablation group (one pericardial effusion, one case of pulmonary edema, one case of pneumonia, one vascular complication, and one case of heart failure). In the drug therapy group, five patients (8.8%) had life-threatening arrhythmias and disabling drug intolerance.
“These data strongly support the use of catheter ablation in patients with paroxysmal AF” who do not respond to initial antiarrhythmic drug therapy, Dr. Wilber and his associates wrote.
