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Catheter Ablation as First-Line Therapy in Persistent AF
Quick Takes
- A first-line catheter ablation strategy for persistent AF (PerAF) is common in the United States, particularly in higher-volume centers.
- Patients with PerAF undergoing catheter ablation as first-line treatment tend to be men with fewer medical comorbidities.
- The clinical outcome of ablation for PerAF is similar between patients undergoing catheter ablation as first- or second-line treatment; however, ablation as a first-line rhythm control strategy lowered the risk of long-term AAD exposure.
Study Questions:
What are the prevalence, patient characteristics, and clinical outcomes of patients with persistent atrial fibrillation (PerAF) who underwent catheter ablation as a first- or second-line strategy?
Methods:
This was an observational study of patients with PerAF at nine hospitals in the United States. Patients were divided into those who underwent ablation as first- or second-line therapy. Patient characteristics and clinical outcomes were compared between the groups.
Results:
There were 2,083 patients who underwent ablation for PerAF. Among those, 1,086 (52%) had ablation as a first-line treatment. Compared to patients treated with antiarrhythmic drugs (AADs) as a first line, these patients were predominantly male (73% vs. 68%) with a lower frequency of hypertension (64% vs. 73%) and heart failure (19% vs. 31%). During a mean follow-up of slightly under 1 year, arrhythmia-free survival was similar between groups; however, patients in the second-line ablation strategy were more likely to remain on AAD therapy (42% vs. 16%).
Conclusions:
A first-line ablation strategy for PerAF is common in the United States, particularly in men with fewer comorbidities.
Perspective:
The success rate of catheter ablation is higher in paroxysmal AF (PAF) than in PerAF, and catheter ablation has a Class I guideline indication in patients with PAF and Class IIa in those with PerAF. The authors of the present study show that about one half of patients across an assortment of medical centers (both academic and nonacademic, including low and high volume) underwent an ablation for PerAF as first-line treatment before attempting to control the rhythm with AADs. Recent studies suggest that catheter ablation likely outperforms AADs in PerAF, as it does in PAF. Additionally, studies have shown that early rhythm control with catheter ablation is superior to AADs in slowing the progression from PAF to PerAF. In this study, referral for catheter ablation in PerAF as first-line treatment was associated with a 2/3 reduction in the need for AAD therapy after ablation. These data underscore the need for prospective and randomized data to help identify the patients with PerAF who may derive the maximal benefit from catheter ablation as first-line therapy.
Clinical Topics: Arrhythmias and Clinical EP, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias
Keywords: Atrial Fibrillation, Catheter Ablation
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