Clinical Edge

Summaries of Must-Read Clinical Literature, Guidelines, and FDA Actions

Catheter Ablation for Asymptomatic AF Patients

Circulation; 2017 Aug 1; Kalman, Sanders, et al

Catheter ablation may be considered in highly selected asymptomatic patients who understand the risks and benefits and elect to proceed, according to a recently published white paper which discusses whether catheter ablation should be performed for asymptomatic atrial fibrillation (AF). The paper notes that numerous studies have demonstrated the superiority of catheter ablation over pharmacological therapy for maintenance of sinus rhythm in patients with both paroxysmal and persistent AF but also point outs that there are no current randomized studies that have demonstrated a mortality or stroke reduction benefit of rhythm control with catheter ablation over a rate control strategy. With up to 40% of an AF population seemingly asymptomatic, however, that paper asks that in the absence of ongoing studies, is there enough data to support AF ablation in asymptomatic patients? Among the conclusions:

  • Any decision to proceed to ablation in an asymptomatic patient will require a careful discussion of various issues such as:
    • Whether the patient is truly asymptomatic from both a physical and psychological perspective.
    • Overall impact on quality of life.
    • The long-term success rates relevant to the individual.
    • Procedural risks.
  • The number of patients with asymptomatic AF who will elect to undergo ablation is likely to represent a small percentage of the cohort.

Citation:

Kalman JM, Sanders P, Rosso R, Calkins H. Should we perform catheter ablation for asymptomatic atrial fibrillation? Circulation. 2017;136:490-499. doi:10.1161/CIRCULATIONAHA.116.024926.

Commentary:

Atrial fibrillation is common and often asymptomatic. Catheter ablation is increasingly being used as an option to restore sinus rhythm in patients with atrial fibrillation. When compared to antiarrhythmic therapy, ablation has better outcomes.1 However, we should avoid “cognitive bias” in decisions about ablation, because while it has been shown to be superior to antiarrhythmic therapy, neither ablation nor antiarrhythmic therapy has been shown to be better than rate control alone.2,3 The current review of catheter ablation, which expresses caution in widespread use of catheter ablation for asymptomatic patients, seems wise in its conclusions. —Neil Skolnik, MD

  1. Di Biase L, Mohanty P, Mohanty S, et al. Ablation versus amiodarone for treatment of persistent atrial fibrillation in patients with congestive heart failure and an implanted device: Results from the AATAC multicenter randomized trial. Circulation. 2016;:1637–1644. doi:10.1161/CIRCULATIONAHA.115.019406.
  2. Wyse DG, Waldo AL, DiMarco JP, et al. Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med. 2002;347:1825–1833. doi:10.1056/NEJ- Moa021328.
  3. Skolnik NS. Letter re: “Ablation versus amiodarone for treatment of persistent atrial fibrillation in patients with congestive heart failure and an implanted device: Results from the AATAC multicenter randomized trial." Circulation. 2016;134:e187-e188. doi:0.1161/CIRCULATIONAHA.116.023385.

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