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First-Line Radiofrequency Ablation for AF Yields Good, Not Great, Results

February 25, 2014

First-Line Radiofrequency Ablation for AF Yields Good, Not Great, Results

  1. Mark S. Link, MD

In a randomized trial, ablation beat antiarrhythmic drug therapy, but modestly and not without complications.

  1. Mark S. Link, MD

Radiofrequency ablation for atrial fibrillation (AF) is relatively new but already carries a Class I guideline recommendation for patients who have failed to respond to antiarrhythmic drugs (AADs). Now, ablation is being investigated as a first-line therapy for AF (NEJM JW Cardiol Oct 24 2012). In the industry-supported, international RAAFT-2 trial, 127 patients were randomized to treatment with either AADs chosen at investigators' discretion (flecainide, 69%; propafenone, 25%) or AF ablation (radiofrequency pulmonary vein isolation confirmed by entrance block). All patients had experienced ≤4 episodes of AF during the prior 6 months and had no previous history of AAD use or AF ablation. The primary endpoint was AF, atrial flutter, or atrial tachycardia of more than 30 seconds' duration during 2-year follow-up.

The rate of the primary endpoint was 54.6% in the ablation group and 72.1% in the AAD group (hazard ratio, 0.56; 95% confidence interval, 0.35–0.90; P=0.02). No strokes or deaths occurred, but four patients in the ablation group experienced pericardial tamponade. Quality-of-life scores improved in both groups with no significant between-group difference.

Comment

In this trial, radiofrequency ablation was more effective than antiarrhythmic drugs as an initial treatment for atrial fibrillation. Yet the efficacy was modest (more than half of the participants experienced a recurrence) and came at a cost of increased risk for complications. As an editorialist notes, this study bolsters support for the current Class IIb recommendation of ablation as a first-line AF therapy; patient preference and particular clinical circumstances should continue to drive individual decision-making.

  • Disclosures for Mark S. Link, MD at time of publication Editorial boards UpToDate Leadership positions in professional societies American Heart Association (Chair, Core 4; Scientific Sessions)

Citation(s):

Reader Comments (5)

KALLINIKOS TSAKONAS Physician, Cardiology, private

A lot ff pressure"" to persuede"" the medical community that the RFA - of A. Fib. is a first line therapy . in my opinion never in patients over 50 yearw old, with a lot recurences ( > 50%) in "closed" doors and with substantial compications rate. . . the ablate HIS and pace tacnique is more feasible cheapest and safer for rate control of A. Fib. THANK YOY

Warren Greenspan Physician, Critical Care Medicine

The logic of the consensus committees recommendation is flawed. For a non- curative procedure with a significant rate of recurrence and only moderate efficacy with little difference between the two treatment strategies in addition to a much greater serious complication rate, there seems little logic to recommend ablation as a first-line therapy. Remember 30 to 50% of pts. require a repeat procedure.

Friedrich Seidel M.D Physician, Cardiology

Wehre is the rationale of ablation? No signifikant benefit in QOL, but >6% pericardial tamponade! I am shocked! And uncertain how to inform my patients about the tamponade risk of the procedure, which I ascertained my patients until yesterday to be about 1%!
F.Seidel

E S MATE Physician, Internal Medicine, private office

Informative article about a subject of common ocurrence

KELLY, I MD, FACC Physician, Cardiology

WE SHOULD BE CAUTIOUS IN RECOMMENDING ABLATIVE THERAPY AS FIRST LINE THERAPY.
NOT ALL AF HAS THE SAME PATHOLOGIC SUBSTRATE AND ABLATIVE THERAPY MAY BE MORE SUCCESSFUL IN PATIENTS WITH FOCAL AF. HENCE IT SHOULD BE TAILORED AND PATIENT SPECIFIC THERAPY.
THE RISK OF TAMPONADE IS A REAL RISK AND SHOULD BE WEIGHED SERIOUSLY IN OUR RECOMMENDATIONS OF ABLATION AS FIRST LINE THERAPY. A RECURRENCE RATE OF OVER 50% MAY NOT MAKE THIS WORHWHILE.

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