When is catheter ablation a sound option for your patient with A-fib?

What are the benefits of catheter ablation?

Ablation can be achieved through radiofrequency (RF) ablation, cryoablation, or newer, laser-based balloon ablation. Primary outcomes used to determine the success of any options for performing ablation include mortality, stroke, and hospitalization. Other endpoints include maintenance of sinus rhythm, freedom from AF, reduction in AF burden (estimated through patients’ report of symptoms, recurrence rate, need for a second ablation procedure, and serial long-term monitoring through an implantable cardiac monitoring device), quality of life, and prevention of AF progression.³

Patient and disease variables (TABLE 2^11-13). The success rate of catheter ablation, defined as freedom from either symptomatic or asymptomatic episodes of AF, is dependent on several factors,^3,14 including:

• type of AF (paroxysmal or persistent)
• duration and degree of symptoms
• age
• sex
• comorbidities, including heart failure and structural heart or lung disease.

Overall, in patients with paroxysmal AF, an estimated 75% are symptom free 1 year after ablation.¹⁵ Patients with persistent and longstanding persistent AF experience a lower success rate.

Ablation is recommended in patients with symptomatic paroxysmal atrial fibrillation that is refractory to antiarrhythmics or when they are intolerant of these drugs.

RF catheter ablation has demonstrated superiority to AAD in reducing the need for cardioversion (relative risk [RR] = 0.62; 95% CI, 0.47-0.82) and cardiac-related hospitalization (RR = 0.27; 95% CI, 0.10-0.72;) at 12 months in patients with nonparoxysmal AF (persistent or longstanding persistent).¹⁶

Effect on mortality. Among patients with heart failure with reduced ejection fraction, long-term studies of cardiovascular outcomes 5 years post ablation concluded that ablation is associated with a decrease in all-cause mortality (RR = 0.69; 95% CI, 0.54-0.88; P = .003) and a reduction in hospitalization (RR = 0.62; 95% CI, 0.47-0.82; P = .0006); younger (< 65 years) and male patients derive greater benefit.^6,17 Indications for ablation in patients with heart failure are similar to those in patients without heart failure; ablation can therefore be considered for select heart failure patients who remain symptomatic or for whom AAD has failed.³

Older patients. Ablation can be considered for patients > 75 years with symptomatic paroxysmal AF refractory to AAD or who are intolerant of AAD.³ A study that assessed the benefit of catheter ablation reviewed 587 older (> 75 years) patients with AF, of whom 324 were eligible for ablation. Endpoints were maintenance of sinus rhythm, stroke, death, and major bleeding. Return to normal sinus rhythm was an independent factor, associated with a decrease in the risk of mortality among all patient groups that underwent ablation (HR = 0.36; 95% CI, 0.2-0.63; P = .0005). Age > 75 years (HR = 1.09; 95% CI, 1.01-1.16; P > .02) and depressed ejection fraction < 40% (HR = 2.38; 95% CI, 1.28-4.4; P = .006) were determined to be unfavorable parameters for survival.¹⁸

Complications and risks

Complications of catheter ablation for AF, although infrequent, can be severe (TABLE 3³). Early mortality, defined as death during initial admission or 30-day readmission, occurs in approximately 0.5% of cases; half of deaths take place during readmission.¹¹

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