When is catheter ablation a sound option for your patient with A-fib?
Ablation sits far along on the spectrum of atrial fibrillation therapy, where its indications and potential efficacy call for careful consideration.
PRACTICE RECOMMENDATIONS
› Refer patients with atrial fibrillation (AF) to Cardiology for consideration of catheter ablation, a recommended treatment in select cases of (1) symptomatic paroxysmal AF in the setting of intolerance of antiarrhythmic drug therapy and (2) persistence of symptoms despite antiarrhythmic drug therapy. A
› Continue long-term oral anticoagulation therapy post ablation in patients with paroxysmal AF who have undergone catheter ablation if their CHA2DS2–VASc score is ≥ 2 (men) or ≥ 3 (women). C
› Regard catheter ablation as a reasonable alternative to antiarrhythmic drug therapy in select older patients with AF, and refer to a cardiologist as appropriate. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
CASE
At his return visit, Mr. Z says that he is concerned about, first, undergoing catheter ablation at his age and, second, the risks associated with the procedure. You explain that it is true that ablation is ideal in younger patients who have minimal comorbidities and that the risk of complications increases with age—but that there is no cutoff or absolute age contraindication to ablation.
You tell Mr. Z that you will work with him on risk-factor modification in anticipation of ablation. You also assure him that the decision whether to ablate must be a joint one—between him and a cardiologist experienced both in electrophysiology and in performing this highly technical procedure. And you explain that a highly practiced specialist can identify Mr. Z’s risk factors that might make ablation more difficult to perform and affect the long-term outcome.
With Mr. Z’s agreement, you screen for sleep apnea and start him on a lifestyle modification plan to achieve a more ideal weight, explaining that the risk of recurrence of AF after catheter ablation is increased by obesity and sleep apnea, in addition to age. You explain that, based on his CHA2DS2–VASc (congestive heart failure; hypertension; age, ≥ 75 years; diabetes; prior stroke, transient ischemic attack, or thromboembolism; vascular disease; age, 65 to 74 years; sex category) score of 3, he will remain on anticoagulation whether or not he has the ablation.
You refer the patient to the nearest high-volume cardiac ablation center.
Last, you caution Mr. Z that, based on his lipid levels, his 10-year risk of heart disease or stroke is elevated. You recommend treatment with a statin agent while he continues his other medications.
Delivering energy to myocardium
Myocardial tissue in pulmonary veins is responsible for most ectopic electrical impulses in patients with drug-refractory AF. The goal of catheter ablation in AF is destruction (scarring) of tissue that is the source of abnormal vein potentials.15
How RF ablation works. Ablation is most commonly performed using RF energy, a high-frequency form of electrical energy. Electrophysiology studies are carried out at the time of ablation by percutaneous, fluoroscopically guided insertion of 2 to 5 catheters, usually through the femoral or internal jugular vein, which are then positioned within several areas of the heart—usually, the right atrium, bundle of His, right ventricle, and coronary sinus.
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