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Applied Evidence
When is catheter ablation a sound option for your patient with A-fib?
Northside Hospital Gwinnett Family Medicine Residency Program, Strickland Family Medicine Center, Lawrenceville, GA (Dr. Osayande); Northside Hospital Cardiovascular Institute, Atlanta, GA (Dr. Sharma) amimi.osayande@northside.com
Dr. Osayande reported no potential conflict of interest relevant to this article. Dr. Sharma received a grant from Biotronic in 2019 to support an educational conference; was provided with honoraria in 2019 for serving on the speakers’ bureaus of Pfizer and Bristol Myers Squibb; and received financial support for education and training from Medtronic (2018) and from Abbott, manufacturer of the EnSite Precision Cardiac Mapping System described in this article (2018 and 2019).
Complications vary, based on the type and site of ablation.19,20 Cardiac tamponade or perforation, the most life-threatening complications, taken together occur in an estimated 1.9% of patients (odds ratio [OR] = 2.98; 95% CI, 1.36-6.56; P = .007).11 Other in-hospital complications independently predictive of death include any cardiac complications (OR = 12.8; 95% CI, 6.86 to 23.8; P < .001) and neurologic complications (cerebrovascular accident and transient ischemic attack) (OR = 8.72; 95% CI, 2.71-28.1; P < .001).
Other complications that do not cause death but might prolong the hospital stay include pericarditis without effusion, anesthesia-related complications, and vascular-access complications. Patients whose ablation is performed at an institution where the volume of ablations is low are also at higher risk of early mortality (OR = 2.35; 95% CI, 1.33-4.15; P = .003).16
Recurrence is common (TABLE 211-13). Risk of recurrence following ablation is significant; early (within 3 months after ablation) recurrence is seen in 50% of patients.21,22 However, this is a so-called "blanking period"—ie, a temporary period of inflammatory and proarrhythmic changes that are not predictors of later recurrence. The 5-year post-ablation recurrence rate is approximately 25.5%; longstanding persistent and persistent AF and the presence of comorbidities are major risk factors for recurrence.13,23
Recurrence is also associated with the type of procedure; pulmonary vein isolation, alone or in combination with another type of procedure, results in higher long-term success.21,23
Other variables affect outcome (TABLE 211-13). Following AF ablation, patients with nonparoxysmal AF at baseline, advanced age, sleep apnea and obesity, left atrial enlargement, and any structural heart disease tend to have a poorer long-term (5-year) outcome (ie, freedom from extended episodes of AF).3,13,23,24
Patients who undergo repeat procedures have higher arrhythmia-free survival; the highest ablation success rate is for patients with paroxysmal AF.13,23
Exposure to ionizing radiation. Fluoroscopy is required for multiple components of atrial mapping and ablation during RF ablation, including navigation, visualization, and monitoring of catheter placement. Patients undergoing this particular procedure therefore receive significant exposure to ionizing radiation. A reduction in, even complete elimination of, fluoroscopy has been achieved with:
nonfluoroscopic 3-dimensional mapping systems25
intracardiac echocardiography, which utilizes ultrasonographic imaging as the primary visual mode for tracking and manipulating the catheter
