- Catheter ablation is being increasingly used in the management of patients with atrial fibrillation
- Symptom control and improved quality of life are proven outcomes of this intervention
- Ablation shown to improve left ventricular systolic function in selected patients
- Ablation can be offered to some patients as first line therapy of rhythm control
- Associated with a higher early complication rate compared to antiarrhythmic drugs
Since the first reports in 1995, catheter ablation is being increasingly practised.
As a result, cardiovascular physicians increasingly manage patients who undergo catheter ablation, who have previously undergone such a procedure, or who are debating whether to undergo such a procedure. It is therefore important to ensure their awareness of the advantages and issues surrounding this therapeutic modality.
In this session, three speakers presented case reports highlighting key aspects of clinical importance in this context and a panel of 4 other clinician-scientists debated and discussed the presentations. Finally, a 4th speaker provided a take-home message for the audience.
Dr Nielsen described a middle-aged patient with highly symptomatic lone paroxysmal atrial fibrillation who opted for a catheter ablation procedure instead of anti-arrhythmic drugs as a first line rhythm control treatment with a successful outcome. He highlighted the findings of the MANTRA PAF study, which showed equally improved quality of life compared to antiarrhythmic drugs and the RAAFT2 study, which showed fewer arrhythmia recurrences with catheter ablation. He rightly emphasised that catheter ablation as first line rhythm control should only be offered to selected symptomatic patients fully aware of the risks of the procedure and wanting greater symptom control.
The panel pointed out that younger paroxysmal AF patients without structural heart disease, small left atria as well as those with low sinus rhythm heart rates might be good candidates for first line catheter ablation
Dr Kirchhoff presented a patient with recent onset persistent symptomatic atrial fibrillation who underwent catheter ablation after failed rhythm control with drugs and electrical cardioversion. Although the patient required re-ablation for atrial flutter, the therapy otherwise resulted in good symptom control. Catheter ablation for persistent AF is less effective than for paroxysmal AF, but is indicated (Class IIa) for symptomatic persistent AF resistant to antiarrhythmic drugs and even with a class IIB indication for long standing persistent AF.
The panel suggested that small left atrial size, shorter duration of atrial fibrillation and perhaps imaging studies or results of voltage mapping might help select those persistent AF patients most likely to benefit from the ablation.
Dr. Mabo described a patient with persistent AF and an underlying dilated cardiomyopathy with symptoms of heart failure and a low ejection fraction. This patient underwent a catheter ablation procedure after failed rhythm control with amiodarone and electrical cardioversion. Stable sinus rhythm was achieved with symptom improvement but without improvement of systolic LV function.
The panel felt that catheter ablation has an increasingly significant role to play in the management of heart failure with concomitant AF and although the evidence in the literature is limited, catheter ablation of AF should be actively considered in the management of concomitant heart failure. The sequence of onset of AF vs. heart failure, as well as imaging studies including MRI may be of help in predicting improved LV systolic function after catheter ablation of AF.
Dr. De Chillou summarised the session by pointing out that symptomatic patients resistant to drug-based rhythm control were good candidates for catheter ablation of AF. He suggested that ablation of atrial fibrillation early in the course of the disease might halt progression to persistent AF. He underlined the fact that early complications can occur after catheter ablation and that oral anticoagulation before, during and after catheter ablation is very important. He urged continued follow up of these patients in order to ensure optimum control of risk factors and protection from thrombo-embolic events.