Ablation vs Antiarrhythmic for Symptomatic Atrial Fibrillation
abstract & commentary
By John P. DiMarco, MD, PhD
Professor of Medicine, Division of Cardiology, University of Virginia, Charlottesville
Dr. DiMarco is a consultant for Novartis and does research for Medtronic and Guidant.
Synopsis: Pulmonary vein isolation is a feasible first-line approach for this treatment of selected patients with symptomatic atrial fibrillation.
Source: Wazni OM, et.al. Radiofrequency Ablation vs Antiarrhthymic Drugs as First-Line Treatment of Symptomatic Atrial Fibrillation: A Randomized Trial. JAMA. 2005; 293:2634-2640.
Wazni and colleagues report a multicenter, prospective, randomized study comparing catheter ablation and antiarrhythmic drug therapy in patients with relatively new onset, symptomatic atrial fibrillation. The study was conducted at 4 centers in the United States, Italy, and Germany. Patients were randomized to receive either antiarrhythmic drug therapy or pulmonary vein isolation for treatment of atrial fibrillation. Antiarrhythmic drug therapy was selected by the patient’s physician, with recommended regimens consisting of either flecainide, propafenone, or sotalol. Warfarin anticoagulation was initiated and maintained for all patients in the antiarrhythmic drug group. Pulmonary vein isolation was performed using radiofrequency energy. The end point for ablation was complete electrical disconnection of the pulmonary vein antrum from the left atrium. All 4 pulmonary veins were isolated. Patients who underwent pulmonary vein isolation received warfarin for a minimum of 3 months after the procedure. Patients with recurrent atrial fibrillation or pulmonary vein narrowing were continued long-term on warfarin. Follow-up visits were scheduled at 1, 3, 6, and 12 months after study entry. The primary end point of the study was any recurrence of symptomatic AF or asymptomatic AF lasting longer than 15 seconds during Holter or event recording. Events during the first 2 months of follow-up were separately analyzed.
Between December 31, 2001 and July 1, 2002, 70 patients with a mean age of 53 years were enrolled. Most patients had paroxysmal atrial fibrillation, relatively normal left atrial size and normal left ventricular ejection fractions. Gender distribution was not reported. Only 18 of the 70 patients had either structural heart disease or hypertension. During the initial 2 months of follow-up, 20 patients in the antiarrhythmic drug group had recurrence of atrial fibrillation which resulted in 26 hospitalizations for cardioversion and/or medication adjustment. In the pulmonary vein isolation group, 9 patients had atrial fibrillation which did not require hospitalization. Events during the first 2 months were excluded from subsequent analysis, since it was felt this time period was required to drug titration or ablation lesion stabilization. After this 2 month period, symptomatic atrial fibrillation recurrence was seen in 13% of the pulmonary vein isolation group vs 63% of the antiarrhythmic drug group.
Hospitalization was required in 9% of the pulmonary vein isolation group and in 54% of the antiarrhythmic drug group. There were no thromboembolic events in either group. Asymptomatic atrial fibrillation was documented in 16% of the antiarrhythmic drug group and in 2% of the pulmonary vein isolation group. At 6 months follow-up, the improvement in quality of life was significantly better in the pulmonary vein isolation group. Bleeding was noted in 2 patients in the pulmonary vein isolation vs one in the antiarrhythmic drug group. Pulmonary vein stenosis, one mild and one moderate, was seen in 2 patients.
Wazni et al conclude that pulmonary vein isolation is a feasible first-line approach for this treatment of selected patients with symptomatic atrial fibrillation.
Commentary
This paper provides an interesting insight into the value of ablation of atrial fibrillation as first-line therapy. However, patients were entered almost 3 years ago and, during that time, ablation techniques for atrial fibrillation have continued to evolve. Current techniques do not focus on the pulmonary vein isolation approach used here, but often include a wide area, circumferential ablation procedures and targeting of selected areas of disorganized atrial activity during atrial fibrillation. Due to this rapid change in technique, it has been hard to identify a standard procedure whose long-term results can be evaluated. In any event, it appears from the data here that pulmonary vein isolation is a reasonable approach for patients with new or recent onset of paroxysmal atrial fibrillation who wish to avoid drug therapy. The patients entered in this study are not the usual patients who have atrial fibrillation. They were younger and had less structural heart disease, yet such patients often have the most symptoms.
Thus, even though they are also at minimal risk for either stroke or death from their atrial fibrillation, they are the group most likely to have a real symptomatic benefit. However, the risk of complications and the increased incidence of arrhythmias in the first months after an ablation suggest that, for many patients, a trial of antiarrhythmic therapy to see if drug therapy restores reasonable quality of life still seems indicated. In this study, amiodarone was not used, since these were younger individuals with less structural heart disease, in whom avoiding any amiodarone toxicity was desirable.
By John P. DiMarco, MD, PhD Professor of Medicine, Division of Cardiology, University of Virginia, Charlottesville Dr. DiMarco is a consultant for Novartis and does research for Medtronic and Guidant. Synopsis: Pulmonary vein isolation is a feasible first-line approach for this treatment of selected patients with symptomatic atrial fibrillation. Source: Wazni OM, et.al. Radiofrequency Ablation vs Antiarrhthymic Drugs as First-Line Treatment of Symptomatic Atrial Fibrillation: A Randomized Trial. JAMA. 2005; 293:2634-2640.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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