ACC: EPs shouldn't jump the gun on ablation for AF

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NEW ORLEANS--While thousands of ablation procedures are performed to treat atrial fibrillation (AF), there may be many reasons clinicians should hold off on choosing ablation as the best possible form of treatment, said A. John Camm, MD, chair of clinical cardiology at the St. George’s University of London,  during a presentation April 3 at the 60th annual American College of Cardiology (ACC) scientific sessions.

“I’m not a person that is anti-ablation. In fact, I am very pro-ablation but I think there are some fallacies and there are some important issues that we need to probe before accepting ablation as the solution for all forms of atrial fibrillation,” Camm urged.

While Camm said that ablation does result in a reduction in AF and related symptoms, "it is by no means a cure."

A meta-analysis of 21 studies showed evidence that there is a better chance of abolishing AF in paroxysmal AF patients compared with persistant AF patients and the recurrence rate was higher in paroxysmal patients.

“We do know that an ablation procedure is associated with some degree of risk and while it’s not a high degree of risk, there are still some complications with this procedure which cannot be ignored," said Camm. In fact, Camm noted that death occurs in one out of 1,000 ablation patients and stroke occurs in one out of 400 patients. The overall complication has been estimated to be just below 6 percent.

In studies that have evaluated the use of ablation to treat AF, arrhythmia-free survival percentages range from 32 percent to 72 percent, uncovering that ablation is not likely to cure every AF patient.

“There are definitive ways to decipher which patients are better likely to have a good result from a ablation procedure,” said Camm. So what are the indications for left atrial (LA) ablation?

Camm outlined that “LA ablation is indicated for the reduction of symptoms due to recurrent AF in patients who have been refractory to antiarrhythmic drugs particularly those who have minimal or no heart disease."

However, LA ablation is not indicated to:

  • Cure AF;
  • Reduce the risk of pro-arrhythmia;
  • To improve cardiovascular outcomes; or
  • To relieve vulnerable patients from taking anticoagulant therapy.

And while there are no Class III indications for LA ablation, there are relative contraindications. These contraindications include: patients who have few symptoms, those with longer durations of AF, patients with atrial thrombus and those with substantial atrial remodeling or fibrosis, among others.

“These contraindications should all give pause. We need to ask if ablation is an appropriate procedure for this AF patient,” said Camm.

“A left atrial ablation approach should not be a gut reaction and we should decide this on a case by case basis."