Has AF ablation reached first-line status? My Trials & Fibrillations post…

Trials & Fibrillations

Head over to theHeart.org to read my review of the recently released RAAFT 2 trial–a randomized clinical trial of Radiofrequency Ablation vs. Antiarrhythmic Drugs as First-Line Treatment of Symptomatic AF.

The study adds significantly to the growing knowledge of how best to treat AF.

JMM

10 comments

  1. RAAFT 2 and the evolving trend you describe sounds very exciting indeed. From my primary care perspective – my impression is the case you describe is highly select = highly symptomatic PAF in an otherwise healthy young adult – this being the population subset with very high success from radiofrequency ablation.

    Sounds like the choice should be that of the patient’s – made with full informed consent. Initial approach to be tried with simple lifestyle change (cutting out caffeine, alcohol) and perhaps option at intermittent drug treatment – but with early option as you describe (esp. if symptomatic PAF episodes persist) to move to ablation at a much earlier point than in the past.

    Excellent point you also make that IF ablation is opted for – that the patient seek out an experienced EP cardiologist at a center with experience. Bottom line for the primary care perspective – in 2012, IF your patient has a troublesome arrhythmia (esp. reentry tachycardias; AP-related rhythms; atrial flutter or paroxysmal AFib) – early referral to your friendly electrophysiologist is the way to go!

  2. Speaking as a patient who, since my AF first presented 4 years ago, has undergone the full menu of treatments from medication (4 different rhythm meds) to electrocardioversions (7 of them) to ablations (3), I am pleased to see that ablations are moving up the list. In my case, the drugs and shocks did very little; it was not until I was ablated did I start to see some improvement.

  3. From your article:
    “Using the overly strict definition of procedure failure (just 30 seconds of AF)”

    I am ignorant in some of the AF terminology, so could you please clarify that statement:
    1. Does it mean that you have an episode of AF that lasts for 30 seconds during any period of time, or does it mean that you have one heart beat that is irregular during a 30 second period and you do not have another irregular heart beat until five minutes later, or does it mean something that I have no idea what it means?

    Thank you for your consideration.

    1. It’s a good question. It means any episode of AF lasting for 3o seconds. A single beat or two extra beats would not be AF. Those would just be called extra beats or PACs or PVCs.

      The 30-second cutoff is contested. Many feel it too strictly defines failure of ablation–as there are many happy patients out there with rare and brief episodes of AF that most would count as successfully treated.

      1. THANK YOU John – as I was waiting for the EP answer to Jim’s question. My view has always been that it is the patient who is the best judge of whether the ablation was a “success” or not. Someone having too-numerous-to-count long-lasting episodes of PAF who gets ablated and now only has occasional very short self-terminating episodes might be ecstatic with that result …

  4. I was diagnosed with AF two weeks ago and fit the profile that the article describes – no underlying heart issues, easily converted, 57. However, the first dose of propafenol didn’t control me and now my cardiologist is recommending I schedule an ablation. How do I judge whether this is a premature call or right in line with the new findings? He naturally is referring to his partner who has done about 700 ablations “and hasn’t lost anyone yet!” How do I get an unbiased read on the partner’s expertise and the facility’s expertise? I tend to think it’s not one of those “highly experienced” teams you recommend – how to find out?

  5. Even if ablative therapy is a perfectly appropriate intervention – there is no dictum stating you need to have that procedure done now (esp. given easy cardioversion and no underlying heart issues). Realize that AFib epsiodes may (probably will) recur – at which point your priorities may change. In the meantime – look for an excellent cardiologist/EP (like Dr. John) who will advise you of the pros and cons of all of your options – and allow you to decide which among them is best for YOU at this particular time.

    1. Another thought is that if your first episode of AF was associated with any known cause of AF (e.g., you had been doing extreme endurance exercise like Dr. John for some strange reason enjoys, you had been taking a corticosteroid such as prednisone, you had been drinking a lot of alcohol), you might be able to minimize or avoid recurrence by avoiding that trigger in future. If you had chronic heart problems or hypertension, those would be harder to change in a hurry (but not impossible).

      Also, how severely did you suffer when you had it? Waiting to see if you had more episodes would not doom you to a lifetime of AF, but how much would it interfere with your life? Someone who gets a rate of 140 and feels lousy might be a lot more tolerant of possibly having future episodes and trying rate control than someone who gets a rate of 200 and goes to the hospital because she can’t even walk.

      1. Excellent points. You highlight one of the things about AF that makes it so daunting for doctors to take care: patients present so differently. Because of its vast diversity, AF does not lend itself well to protocol and systems-heavy care. It amazes me how one patient with AF doesn’t even they are in it, and the next patient is nearly incapacitated by 2 minutes of it.

        On the triggers…you are spot on.

        Thanks for saying.

  6. Cathy B, my family doctor was a big help in deciding whether to ablate. My electrophysiologist provided me with the cold facts regarding success rates and the possible complications and their likelihood. My family doctor helped me put that information in context with regards to my quality of life expectations. He also assured me that, based on the feedback from his patients that had been referred there, the EP clinic that was working with me was as good as any in the country (Canada, in my case).

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