Should We Perform Catheter Ablation for Asymptomatic Atrial Fibrillation?

Abstract

Since the original description of atrial fibrillation ablation, numerous studies have demonstrated the superiority of catheter ablation over pharmacological therapy for maintenance of sinus rhythm in patients with both paroxysmal and persistent atrial fibrillation. However, to date, no randomized studies have been powered to demonstrate a mortality or stroke reduction benefit of rhythm control with catheter ablation over a rate control strategy. The results of such ongoing studies are not expected until 2018 or 2019. Thus, the only indication for atrial fibrillation ablation in recent guidelines has been the presence of symptoms. However, up to 40% of an atrial fibrillation population may be asymptomatic. In 2017, in the absence of randomized studies, are there nevertheless data that support atrial fibrillation ablation in asymptomatic patients?

Management of asymptomatic arrhythmias: a European Heart Rhythm Association (EHRA) consensus document, endorsed by the Heart Failure Association (HFA), Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), Cardiac Arrhythmia Society of Southern Africa (CASSA), and Latin America Heart Rhythm Society (LAHRS)

“…Whether (and how) asymptomatic AF patients could benefit from AF ablation still needs to be established. Incidental diagnosis of AF may trigger symptoms in susceptible patients as they become aware of a heart condition, 137 and even failed AF ablation may have a placebo effect in such patients. 138 A challenge with rhythm control (e.g.…”

“…using electrical cardioversion) could identify apparently asymptomatic patients who had subconsciously adapted to AF by restricting their lifestyle or have atypical symptoms. 77,137 In many cases, a trial with an antiarrhythmic drug might be considered after cardioversion before considering ablation. Whereas these patients would likely experience symptomatic improvement after successful AF ablation, 138 a failed procedure may turn truly asymptomatic patients into symptomatic due to post-procedural atrial tachyarrhythmias (such a scenario has been reported in 24-34% of patients).…”

Impact of atrial fibrillation catheter ablation on mortality, stroke, and heart failure hospitalizations: A meta‐analysis

“…These studies have, however, been widely debated, being generally underpowered to reveal a possible impact on the aforementioned outcomes in patients undergoing AFCA 5 or affected by crossovers between the study arms 6 . On the contrary, evidence from observational matched databases/registry studies suggest a net benefit of AFCA in terms of hard clinical endpoint reductions 7,8 …”

Cardiac electrophysiological characteristics of silent paroxysmal atrial fibrillation: What causes asymptomaticity?

“…15 A reduction in the mortality or stroke risk with AF ablation has not yet been shown. 16 Therefore, the only indication for AF ablation in the recent guidelines has been the presence of symptoms 5,15 In our series, the freedom from AF after the ablation was not inferior in the patient with silent paroxysmal AF as compared to that in those with symptomatic paroxysmal AF. However, two important questions remain because they were asymptomatic: (a) Were some incidences of recurrent AF missed?…”