A-Fib is age related. In particular, more people in their 80s are developing A-Fib.
Yet many A-Fib centers have a policy of not performing a catheter ablation on anyone 80 years old or older. But these are often the patients who need a PVI the most. Up to 25% of strokes occurring in octogenarians can be attributed to A-Fib.
It seems arbitrarily cruel to force someone to “live in A-Fib” just because they are older.
It seems arbitrarily cruel to force someone to “live in A-Fib” just because they are older. Isn’t this age discrimination? Why exclude octogenarians from a potentially curative treatment like catheter ablation (PVI)?
Study of Octogenarians Who Had a Catheter Ablation (PVI)
Dr. Pasquale Santangeli and his colleagues at the Texas Cardiac Arrhythmia Institute in Austin, TX examined data from 103 octogenarians who had an RF catheter ablation between 2008 and 2011. They compared this older group to younger patients who underwent the same procedure.
• There was no difference in the rate of success between the octogenarians and the younger group (69% vs. 71%).
• The rate of procedure-related complications was also not significantly different between the two groups, even when looking at different types of A-Fib such as paroxysmal and non-paroxysmal A-Fib.
• Octogenarians with paroxysmal A-Fib had more non-pulmonary vein trigger sites, and consequently required longer procedural time to effectively isolate such non-pulmonary vein areas. (Dr. Santangeli suggested a hypothesis that the underlying pathology of A-Fib in older patients might be different from younger patients.)
What Patients Need To Know
If you’re in your 80s, you’re not automatically doomed to a life in A-Fib and on A-Fib drugs. Dr. Santangeli’s work is very hopeful and encouraging. …Continue reading…
10. I am 82 years old. Am I too old to have a successful Pulmonary Vein Ablation? What doctors or medical centers perform PVAs on patients my age?”
This is a very important question since so many people in their 80s are getting A-Fib. 8-10% of people in their 80s have A-Fib. Recent studies indicate you are certainly not too old to have a successful Pulmonary Vein Ablation.
1. “Age should not preclude patients from A-Fib ablation,” according to the authors of a study comparing catheter ablation to antiarrhythmic drugs (AADs) in the elderly. 412 patients aged 70 years or older with symptomatic persistent A-Fib refractory to at least one AAD choose either ablation or AAD treatment. Pulmonary Vein Isolation (PVI) and right atrium cavotricuspid isthmus (Flutter) ablation were performed in the entire ablation group. 60% also received left atrium linear lesions at the roof and left isthmus.
The AAD group underwent electrical cardioversion (ECV) after four weeks of AAD and continued the AAD thereafter. Catheter ablation in the elderly was more effective in maintaining sinus rhythm (SR) than AAD (76% vs, 46%). And due to the higher rate of SR maintenance, the ablation group was more likely to discontinue AADs (67% vs. 28%) and oral anticoagulants (74% vs. 43%), “with a consequent greater reduction of long-term adverse events (7.7% vs. 23.9%) and greater improvement in quality of life.” (Elderly patients with a previous history of TIA/stroke had more cerebral thromboembolisms (strokes) during the ablation procedure.)
2. In a study of 103 octogenarians (with four over 90 years old) who had an A-Fib ablation and were followed for 18 months, 69% of the octogenarians were A-Fib free without AAD after a single procedure compared to 71% of those younger than 80 (no significant difference). The success rate increased to 87% after two procedures.
3. Another study looked at A-Fib ablation in patients over 80 years old vs. younger patients. The hospital stay was longer in the older patients, but there was no increased risk of complications. One-year survival free of A-Fib or Flutter was 78% in those older than 80 and 75% in those younger (no significant difference).
4. A multicenter study looked at 175 patients older than 75 who underwent catheter ablation for symptomatic A-Fib with a mean follow-up of 20 months. The ablation procedure consisted of pulmonary vein antrum isolation and isolation of the superior vena cava. 73% maintained sinus rhythm (SR) after a single ablation procedure, and the complication rate was 1%. After a second ablation, 82% maintained SR without AADs. An additional 22 patients were able to maintain SR with AADs. Thus 94% of patients older than 75 remained in SR at almost 2 years of follow-up with a very low rate of major procedure-related complications.
The above studies demonstrate conclusively that for people over 80, not only can you have an A-Fib ablation, you probably should—especially compared to living the rest of your life on antiarrhythmic (AADs) and anticoagulant drugs. AADs produce much more long-term adverse events than an A-Fib ablation. But more importantly, a successful A-Fib ablation produces a dramatic improvement in one’s quality of life that is indeed life-changing. Ask anyone who’s had A-Fib what it’s like to have a heart that beats normally again.
If you’re over 80, many cardiologists will put you on antiarrhythmic (AADs) and anticoagulant drugs rather than refer you to an EP for an A-Fib ablation. But, all things considered, this may not be in your best interest. If this happens to you, don’t hesitate about getting a second opinion.
Some say that people over 80 years old shouldn’t have an A-Fib ablation because they are often sicker or more frail than younger people. But that isn’t always the case. People who live into their 80s often have more healthy life habits such as not smoking, good diet, aren’t overweight, low cholesterol, don’t binge drink, are more often female, take better care of themselves, and are more likely to seek good medical care if problems arise. In one study the most elderly (over 85) had a much lower complication rate (2.5%) than younger patients.
If you do have other illnesses besides A-Fib and are over 80 years old, obviously you need to take care of the more life-threatening illnesses first. But an A-Fib ablation may improve your overall health and your other illnesses, because of the improvement in your circulation and blood flow from being in normal sinus rhythm. EPs should do a thorough examination of you before designating you for an A-Fib ablation. They are unlikely to perform an ablation on someone very ill or near death’s door.
Ultimately whether or not to have an A-Fib ablation is a question only you and your doctor can answer based on your individual needs, health, medical history, how your A-Fib affects you, etc.
Centers that perform ablations on 80-year-olds
¤ Dr. Andrea Natale and his colleagues around the US are known for their success in ablating older patients. See:
• Texas Cardiac Arrhythmia Institute/St. David’s Medical Center/ Univ. of Texas in Austin
• California Pacific Medical Center in San Francisco, CA
• Scripps Clinic in La Jolla, CA
¤ Intermountain Heart Rhythm Specialists in Murray, UT (near Salt Lake City)
¤ Go, “Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) study. Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention.” JAMA, 2001:285:2370-2375. Last accessed 9/25/2014. http://www.ncbi.nlm.nih.gov/pubmed/11343485
¤ Blandino et al. Long-term efficacy and safety of two different rhythm control strategies in elderly patients with symptomatic persistent atrial fibrillation. J Cardiovasc Electrophysiol. 2013;July 24(7):731-8. Last accessed 9/25/2014. http://www.ncbi.nlm.nih.gov/pubmed/23551460. doi: 10.1111/jce.12126. Epub 2013 Apr 1
¤ Santangeli et al. Catheter ablation in octogenarians: Safety and outcomes. J. Cardiovasc Electrophysiol 2012;23:687-693. Last accessed 9/25/2014. http://www.ncbi.nlm.nih.gov/pubmed/22494628 doi: 10.1111/j.1540-8167.2012.02293.x. Epub 2012 Apr 11
¤ Bunch, TJ et al. Long-term clinical efficacy and risk of catheter ablation for atrial fibrillation in octogenarians. Pacing Clin Electrophysiol 2010;33:146-152. Last accessed 9/25/2014. http://www.ncbi.nlm.nih.gov/pubmed/19889181. doi: 10.1111/j.1540-8159.2009.02604.x. Epub 2009 Nov 2.
¤ Corrado, A. et al. Efficacy, safety, and outcome of atrial fibrillation ablation in septuagenarians. J. Cardiovasc Electrophysiol 2008;19:812-814. Last accessed 9/25/2014. http://www.ncbi.nlm.nih.gov/pubmed/18363688. doi: 10.1111/j.1540-8167.2008.01124.x. Epub 2008 Mar 21
¤ Ellis, E. et al. Trends in utilization and complications of AF Ablation in Medicare patients. Heart Rhythm 2009;6:1267-1273. Last accessed 9/25/2014. http://www.heartrhythmjournal.com/article/S1547-5271%2809%2900618-3/abstract. DOI: http://dx.doi.org/10.1016/j.hrthm.2009.06.009
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