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
There is no absolute age or comorbidity contraindication to ablation. The patient should be referred to a cardiologist who has received appropriate training in electrophysiology, to identify comorbidities that (1) increase the technical difficulty of the procedure and baseline risk and (2) affect long-term outcome,12 and who performs the procedure in a center that has considerable experience with catheter ablation.33
Once the decision is made to perform ablation, you can provide strategies that optimize the outcome (freedom from AF episodes). Those tactics include weight loss and screening evaluation and, if indicated, treatment for sleep apnea.3
Protocol. Prior to the procedure, the patient fasts overnight; they might be asked to taper or discontinue cardiac medications that have electrophysiologic effects. Studies suggest a low risk of bleeding associated with catheter ablation; anticoagulation should therefore continue uninterrupted for patients undergoing catheter ablation for AF3,4,34,35; however, this practice varies with the cardiologist or electrophysiologist performing ablation.
Because of the length and complexity of the procedure, electro-anatomical mapping and ablation are conducted with the patient under general anesthesia.3 The patient is kept supine, and remains so for 2 to 4 hours afterward to allow for hemostasis at puncture sites.3
Patients might be monitored overnight, although same-day catheter ablation has been shown to be safe and cost-effective in select patients.36,37 Post ablation, patients follow up with the cardiologist and electrophysiologist. Long-term arrhythmia monitoring is required.3 Anticoagulation is continued for at least 2 months, and is discontinued based on the patient’s risk for stroke, utilizing their CHA2DS2–VASc score.3,4
CASE
At Mr. Z’s 6-month primary care follow-up, he confirms what has been reported to you as the referring physician: He had a successful catheter ablation and continues to have regular follow-up monitoring with the cardiologist. He is no longer taking amiodarone.
At this visit, he reports no recurrence of AF-associated symptoms or detectable AF on cardiac monitoring. He has lost 8 lbs. You counsel to him to continue to maintain a healthy lifestyle.
CORRESPONDENCE
Amimi S. Osayande MD, FAAFP, Northside-Gwinnett Family Medicine Residency Program, Strickland Family Medicine Center, 665 Duluth Highway, Suite 501, Lawrenceville, GA 30046; amimi.osayande@northside.com
