ACC: Should catheter ablation be first-line for AF?

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NEW ORLEANS—Catheter ablation is superior to antiarrhythmic drug treatment and should be the method of choice after atrial fibrillation (AF) patients fail antiarrhythmic drug treatment, said Karl-Heinz Kuck, MD, of the Asklepios Klinik St Georg in Hamburg, Germany, during a presentation at the annual meeting of the American College of Cardiology (ACC).

Kuck and A. John Camm, MD, participated in a point-counterpoint discussion April 3 about why it might be best to delay the choice of catheter ablation or employ it as an early intervention strategy for patients in AF.

“First, you need to make the decision on whether you want to go into rhythm control or rate control and once you have made that decision, the question is whether you will first treat the patient with antiarrhythmic drugs and then catheter ablation,” Kuck offered.

While he said the type of AF will play an important role, the first decision will be whether to use rhythm control. While the AFFIRM trial showed no benefit of using rhythm control, it also showed that patients who achieved and maintained sinus rhythm had an almost significant reduction in overall mortality, however the use of antiarrhythmic drugs increased mortality by almost the same amount.

“Data tell us that if we have treatment that can maintain sinus rhythm without the use of antiarrhythmic drugs, this therapy would have the potential to improve the arrhythmia,” said Kuck.

“Being in sinus rhythm most likely will not be worse, and I strongly believe it will be better than being in atrial fibrillation for a variety of reasons."

Results from the randomized ThermoCool AF study showed that patients who received ablation saw a significant reduction in the amount of recurrences compared to those on antiarrhythmic drugs at nine months.

“We concluded that the amount of recurrence is significantly lower in patients treated with catheter ablation compared to antiarrhythmic drugs and they also profited from the improvement of symptoms significantly including quality of life," Kuck noted.

“Should we ablate early in the course of AF or late?” asked Kuck. “What we know from catheter ablation studies is that long-term results of paroxysmal atrial fibrillation patients are much better than those in long-standing persistent atrial fibrillation.”

So, can an early ablation at the time of paroxysmal AF really prevent the conversion of paroxysmal AF into persistent forms of AF?

“Evidence in non-randomized trials suggests that we might be able to prevent the progression of persistent forms of AF and thereby improve the results of catheter ablation,” said Kuck. “Catheter ablation is superior to drug treatment in AF, it should be the method of choice in patients after failure of one antiarrhythmic drug and I would not test the second, third or fourth drug before moving to catheter ablation. We should move there early.”

He said that eventually catheter ablation may become a first-line treatment strategy in selected AF patients; however, it should be performed in very experienced centers to avoid complications.

“Catheter ablation should be considered early in the course of AF since long-term results are significantly better in paroxysmal patients compared with long-standing AF patients,” he concluded. “I would not wait until patients move into persistent forms of atrial fibrillation to perform catheter ablation.”

However, Kuck did offer that a large controlled trial will be necessary to understand whether an earlier, rather than later, approach to catheter ablation is best.