Should Catheter Ablation Be Indicated Only for Symptom‐Relief of AF?
Notice bibliographique
Résumé
Should Catheter Ablation Be Indicated Onlyfor Symptom-Relief of AF?Atrial fibrillation (AF) is the most common arrhythmia, particularly in seniors, with an incidence of 4% after the age of 65 with the figure doubling with every 10 years of age.][3] Persistence of left atrial (LA) volume and pressure overloading during AF due to loss of atrial contraction, shortened diastolic ventricular filling and atrio-ventricular valvular regurgitation leads to atrial anatomical and electrical remodeling which further facilitates persistence of AF. 4) Canadian Registry of AF reported that the probability of progression of paroxysmal AF (PAF) to chronic AF (CAF) (defined as AF on 2 consecutive electrocardiograms separated by ! 1 week) was 8.6% by 1 year. 5)This malignant cycle should be interrupted immediately by restoration and longlasting maintenance of sinus rhythm (SR).New on-treatment analysis of the AFFIRM study revealed that presence of SR was associated with a 47% reduction of death and use of antiarrhythmic drugs (AAD) was associated with significant increase of mortality by 49%. 6) This suggests favorable AAD effect for AF termination might be offset by its potentially life-threatening adverse effects, and minimally invasive non-pharmacological treatment without acceptable risks, i.e. catheter ablation (CA), must be considered first-line therapy.Superiority of catheter ablation (CA) to AAD in AF rhythm control has been shown by recent meta-analyses.The recent meta-analysis of randomized, controlled trials comparing pulmonary vein isolation and medical therapy by Piccini et al 7) showed markedly higher AF-free survival rate at 1 year in CA (77% vs 29%).According to another meta-analysis by Calkins et al, 8) multiple CA showed higher efficacy of CA (71% vs 52%) and also a lower rate of adverse effects (5% vs 30%).As the above shows, CA appears to have an acceptable efficacy and risk of major complication without any equivalent minimally invasive alternative therapy for treatment of AF.However, HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of AF 9) published in 2007 stated that the primary selection of CA is symptomatic AF refractory or intolerant to at least one Class 1 or 3 AAD, and recent ESC guidelines 10) published in 2010 also stated CA as first-line therapy is a Class IIb recommendation for patients with paroxysmal AF with no or minimal heart disease, who remain highly symptomatic despite rate control and who reject AAD therapy, otherwise for drugrefractory and symptomatic paroxysmal and persistent AF have second-line indication with Class IIa and IIb recommendation, respectively.In these guidelines, CA is officially unjustifiable for asymptomatic AF because of the potential risk of major complications, even if their incidences are recognized to be very low.However, there is increasing evidence that restoration and maintenance of SR confers benefits as a consequence of reverse electrical and anatomical remodeling of the atrium and ventricle.The ongoing CABANA (Catheter Ablation vs Antiarrhythmic Drug therapy for AF) Trial conducted by Packer DL et al, 11) which is designed to investigate the impact of CA for AF on survival with a primary endpoint of all-cause mortality, a planned recruitment of 3000 patients and a follow-up period of 3.5 years, might be anticipated to show evidence of CA as a promising first-line therapy for AF.
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