2014 Boston AF Symposium

CATHETER ABLATION AS RECOMMENDED FIRST CHOICE

Report by Dr. Steve S. Ryan, PhD, August 26, 2014

Dr. Hugh Calkins from Johns Hopkins gave a presentation entitled “Indications for AF Ablation: Guidelines vs. Clinical Reality.” To begin his presentation, Dr. Calkins asked the Symposium attendees: Which statement correctly reflects your current approach to AF ablation as first line therapy in patients with symptomatic paroxysmal AF?

• I rarely recommend AF ablation as first line therapy in this patient group.
• I routinely recommend AF ablation as first line therapy in this patient group.

79% of the attendees selected choice #1.

CURRENT GUIDELINES

According to the 2012 Guidelines (ESC Focused Update),

“Symptomatic AF refractory or intolerant to at least one Class 2 or 3 antiarrhythmic medication, catheter ablation is recommended.” With the following footnote: “Catheter ablation of symptomatic AF is considered a Class 1 indication only when performed by an electrophysiologist who has received appropriate training and is performing the procedure in an experienced center.”

“Symptomatic AF prior to initiation of antiarrhythmic drug therapy with a class 2 or 3 antiarrhythmic, Catheter ablation is reasonable.”

(If a paroxysmal patient has no or minimal structural heart disease, their first line choice can be catheter ablation or the antiarrhythmic meds dronedarone, flecainide, propafenone, or sotalol. Should these antiarrhythmics fail, the patient can choose catheter ablation or amiodarone.)

Dr. Calkins also asked “And What About Ablation in Patients with Asymptomatic AF?” He notes that the indications listed in all guidelines refer only to patients with symptomatic atrial fibrillation. No mention is made of asymptomatic AF. In rare circumstances, it may be reasonable to perform AF ablation in a truly asymptomatic patient with the aim of reducing long term consequences of AF including increased risk of stroke, heart failure, and dementia. But patients need to be aware of the immediate risks of AF ablation and also that AF ablation has not been shown to reduce the risks of stroke, heart failure, or dementia. (But see a study recently published after Dr. Calkins’ presentation Live Longer—Have a Catheter Ablation. In this research they found that a successful PVI reduces by 60% the risk of death from stroke and other cardiovascular events. [Some consider this study flawed, that it may not correct for important differences in those who get an ablation and in those who don’t.])

ABLATION VS ANTIARRHYTHMIC meds

Dr. Calkins cited a study comparing Radiofrequency Ablation vs. Antiarrhythmic Drugs as First-line Treatment of Symptomatic Atrial Fibrillation. The A-Fib free success rate was significantly higher for catheter ablation. The study concluded “Pulmonary vein isolation appears to be a feasible first-line approach for treating patients with symptomatic AF.¹

But what about possible complications from catheter ablation. (For a more extensive discussion of this topic, see Dr. Keane’s earlier Symposium presentation Risk of Complications from a Catheter Ablation.) Dr. Calkins discussed the RAAFT 2 randomized clinical trial. The CA arm had a 7.7% complication rate compared to 19% for patients on antiarrhythmics (AADs). The success rate for CA was 45% (low compared to other studies), while the success rate for AADs was only 28%. 59% in the AAQD arm had to stop at least one drug and nearly half did choose to have a catheter ablation.

In another study, the overall complication rate was 6.9% in patients undergoing AF ablation. But more importantly, the study concluded “there was a significant association between operator and hospital volume and adverse outcomes.” ²

DR. CALKINS’ CONCLUSIONS

• I think the guidelines have gotten it right.
• It is difficult to advise that all patients undergo AF ablation as first line therapy given that AF ablation is associated with a significant risk of major complications including death.
• Clearly a patient’s values and preferences play a big role.
• But of equal importance is the operator’s own data on success and complications.
• There is increasing evidence that experience matters when it comes to the outcomes of AF ablation. Most experienced operators have waiting lists.
• While waiting for an experienced operator, you might as well try an AA drug.
• It is my impression that the Guidelines are being adhered to. Most patients undergoing ablation today have failed at least one antiarrhythmic medication and have symptomatic AF.
• Consistent with the guidelines, in rare situations select patients are undergoing ablation as first line therapy.
• Some asymptomatic or minimally symptomatic patients are undergoing ablation for “theoretical reasons”. In my mind, this is acceptable provided adequate informed consent has been obtained and patients are aware that the only proven benefit of AF ablation is to improve quality of life.

EDITOR’S COMMENTS:

PROBLEMS WITH TODAY’S ANTIARRHYTHMIC MEDS

Doctors know all too well that today’s antiarrhythmic meds don’t work very well, or they have bad side effects, or they lose their effectiveness over time. They also tend to cause more and more lasting adverse events than catheter ablation. It’s often safer to have an ablation than to not have one. And the complications from a catheter ablation are most often temporary as compared to living a life in A-Fib or on A-Fib meds.

Also, one of the main reasons people have a catheter ablation is so that they don’t have to take antiarrhythmic meds and anticoagulants for the rest of their lives.

CATHETER ABLATION FIRST-LINE CHOICE

Today’s guidelines happily take into account these realities. According to current guidelines, you don’t have to spend months or a year trying various antiarrhythmic meds while your A-Fib gets worse, your heart develops more fibrosis, “remodels” itself, and your quality of life is in the  toilet.

Then why did 79% of the attendees not recommend A-Fib ablation as first-line therapy? Because, even though catheter ablation is a low risk procedure, it isn’t risk free. (The risk is similar to having your tubes tied. By comparison, the risks of an appendectomy are around 18%.)

KNOW YOUR RIGHTS—YOU MAY HAVE TO BE ASSERTIVE

As an A-Fib patient, you may have to know your rights and be assertive—that according to the guidelines, you have a right to choose catheter ablation as your first choice. Your doctor may try to talk you into first trying antiarrhythmic meds before offering you the option of a catheter ablation. (The author frequently hears of Cardiologists who refuse to refer patients for a catheter ablation, who tell patients a catheter ablation is unproven and dangerous. When you hear something like that, it’s time to dump that doctor and get a second opinion.)

CATHETER ABLATION RECOMMENDED OR A REASONABLE OPTION

Current guidelines “recommend” catheter ablation or say it is a “reasonable” option.

CATHETER ABLATION FOR PATIENTS WITHOUT SYMPTOMS

Dr. Calkins, who headed the committee which drafted the guidelines, goes even further. Patients without symptoms or with minimum symptoms can get a catheter ablation.

”In my mind this is acceptable provided adequate informed consent has been obtained and patients are aware that the only proven benefit of AF ablation is to improve quality of life.”

(It’s questionable whether anyone with A-Fib is really symptom-free. If you have A-Fib, the upper parts of your heart (the atria) aren’t pumping properly. Your body and brain are losing 15% to 30% of their normal blood flow. People get used to it or they write off the increased fatigue, tiredness, mental slowness, etc. as old age. But anyone with A-Fib is affected by it to some extent.)

If you have A-Fib and are symptom-free, you have the option of simply living out the rest of your life in A-Fib. But some people may not be able to do this without worrying about it, “How is the A-Fib affecting my heart, how much fibrosis am I developing, how is my heart remodeling over time?” Realize that you can choose to have a catheter ablation for what Dr. Calkins terms “theoretical reasons”.  

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