Treatment of Atrial Fibrillation With Antiarrhythmic Drugs or Radiofrequency Ablation

Abstract

Background-Although radiofrequency catheter ablation (RFA) has evolved from an experimental procedure to an important treatment option for atrial fibrillation, the relative safety and efficacy of catheter ablation relative to that of antiarrhythmic drug (AAD) therapy has not been established. Methods and Results-Two separate systematic reviews were conducted: one on RFA and the other on AAD to provide accurate and broadly representative estimates of the clinical efficacy and safety of both therapies in the treatment of atrial fibrillation. Electronic searches were conducted in EMBASE and MEDLINE from 1990 to 2007. For the RFA review, all study designs were accepted. For the AAD review, articles were limited to prospective studies on the following drugs of interest: amiodarone, dofetilide, sotalol, flecainide, and propafenone. Data were extracted by 1 reviewer, with a second reviewer performing independent confirmation of extracted data. Sixty-three RFA and 34 AAD studies were included in the reviews. Patients enrolled in RFA studies tended to be younger (mean age, 55 versus 62 years), had longer duration of atrial fibrillation (6.0 versus 3.1 years), and had failed a greater number of prior drug trials (2.6 versus 1.7). The single-procedure success rate of ablation off AAD therapy was 57% (95% CI, 50% to 64%), the multiple procedure success rate off AAD was 71% (95% CI, 65% to 77%), and the multiple procedure success rate on AAD or with unknown AAD usage was 77% (95% CI, 73% to 81%). In comparison, the success rate for AAD therapy was 52% (95% CI, 47% to 57%). A major complication of catheter ablation occurred in 4.9% of patients. Adverse events for AAD studies, although more common (30% versus 5%), were less severe. Conclusions-Studies of RFA for treatment of atrial fibrillation report higher efficacy rates than do studies of AAD therapy and a lower rate of complications. (Circ Arrhythmia Electrophysiol. 2009;2:349-361.)

2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: Recommendations for Patient Selection, Procedural Techniques, Patient Management and Follow-up, Definitions, Endpoints, and Research Trial Design

“…262,1031,1032 Pooling of results across trials indicates that AF ablation is clearly superior to AAD therapy for the maintenance of sinus rhythm. The impact of AF ablation on other key outcomes, including HF, stroke, and QOL, will be reviewed in subsequent sections of this document.…”

Cryoballoon Ablation for Atrial Fibrillation

“…[11] CBA resulted in a high procedural success rate (>98% of patients achieving complete PVI) and 1-year freedom from recurrent AF (single cryoballoon procedure off anti-arrhythmic drugs 1-year success of 60%; 73% if a 3-month blacking period was included) [11,12]. In comparison, the longer-term freedom from recurrent AF after RF catheter ablation has been reported to be 50% to 64% after a mean follow-up of 14 months in the meta-analysis by Calkins et al and 39.8±5.1% at 1 year in the prospective long-term cohort study by Weerasooriya et al[7,13] Thus, the early experience suggests that cryoballoon ablation is efficacious for the maintenance of sinus rhythm at 1 year in patients with paroxysmal AF.…”

“…Major complications have been reported in approximately 5-6% of patients undergoing RF ablation for AF [7,9,10]. The rate of acute procedural complications reported with cryoballoon-based ablation (CBA) is relatively low (<3-5%) and compares favourably with irrigated RF and duty-cycled multi-electrode RF ablation [7,9,10,21].…”

“…Radiofrequency (RF) catheter ablation has shown considerable success in treating symptomatic AF, particularly in comparison to anti-arrhythmic drugs [7,8]. Unfortunately, major complications including thromboembolism, cardiac perforation, and injury to adjacent structures are not infrequently observed [2,3,7,9,10].…”

“…Unfortunately, major complications including thromboembolism, cardiac perforation, and injury to adjacent structures are not infrequently observed [2,3,7,9,10]. Further, the procedure is complex, time-consuming and highly dependent on operator competency given the inherent difficulties associated with creating contiguous curvilinear lesions with a technique originally developed for focal ablation.…”