Ablation effective second-line treatment in long-standing PAF
?There is currently much interest in radio-frequency ablation as a potentially curative procedure in atrial fibrillation (AF). Good evidence exists to support the use of radio-frequency pulmonary vein ablation in patients with a new presentation of paroxysmal atrial fibrillation (PAF), but the role of ablation in long-standing PAF is less clear. However, new evidence suggests that ablation may be an effective second-line strategy in patients with long-standing PAF.
The APAF study, although relatively small because of its highly specialised content, compares pulmonary vein ablation with antiarrhythmic drug therapy in patients with PAF. The study recruited 198 patients, with PAF of 6 ± 5 years' duration with a mean occurrence of 3.4 episodes/month, who had already failed to achieve control on one antiarrhythmic drug. They were randomised to either an ablation strategy or an alternative antiarrhythmic drug (including flecainide, sotalol and amiodarone).
The results were very encouraging, with 93 per cent of the ablation group free of recurrence compared with only 35 per cent of the drug group at one year. In the drug group, hypertension, ejection fraction and age independently predicted AF recurrence, and 23 patients had side-effects. In the ablation group there was one case of transient ischaemic attack and one case of pericardial effusion.
In patients with long-standing symptomatic PAF the initial priority is to administer appropriate thromboprophylaxis. However, in patients who fail to respond to antiarrhythmic drug therapy (and/or a standard ß-blocker), referral to an electophysiologist for consideration of ablation can be a more effective treatment strategy than switching to an alternative antiarrhythmic agent.
Pappone C, Augello G, Sala S, et al. A Randomized Trial of Circumferential Pulmonary Vein Ablation Versus Antiarrhythmic Drug Therapy in Paroxysmal Atrial Fibrillation J Am Coll Cardiol 2006;48:2340-7Reviewer
Dr Peter Savill
GPSI Cardiology, Southampton