Ablation for atrial fibrillation

See ((Radiofrequency ablation for atrial fibrillation))

Indicated for Parkinson White syndrome, ventricular tachycardia, incessant atria tachycardia, atrial flutter, atrial fibrillation and atrioventricular nodal reentrant tachycardia.

Pulmonary vein isolation may cure atrial fibrillation and obviate the need for long term antiarrhythmic drugs and anticoagulants.

Indicated when a patients has a rapid rhythm for most of the day causing impaired cardiac function-tachycardiomyopathy.

For atrial fibrillation it is efficacious for reducing morbidity, and improving functional capacity.

In retrospective studies for atrial fibrillation reduced mortality compared to anti- arrhythmic medications.

Left atrial fibrosis, is  a hallmark of atrial myopathy, and plays an important role in the pathophysiology of AF.

Higher baseline left atrial fibrosis determined by cardiac MRI, is independently associated with atrial arrhythmia recurrence after ablation.

In a prospective, multicenter randomized trial of 167 patients that did not respond to at least one antiarrhythmic drug and who experienced at least 3 AF episodes within 6 months of randomization, to catheter ablation or to antiarrhythmic drug therapy: at the end of 9 months 66% of patients treated in the catheter group remained free from protocol treatment failure, compared to 16% of antiarrhythmic drug patients (Wilber DJ).

Efficacy similar for patients with atrial fibrillation and heart failure and low ejection fraction.

Biventricular pacing found to be superior to right ventricular pacing after atrioventricular node ablation.

Catheter ablation is more effective than drug therapy for reducing atrial fibrillation recurrence, but has a failure rate of 20-50%, and a common need for repeat procedures.

Among patients with paroxysmal atrial fibrillation and hypertension, renal denervation added to catheter ablation, compared with catheter ablation alone, significantly increased the likelihood of freedom from atrial fibrillation at 12 months (Steinbrenners JS).

The Pulmonary Vein Antrum Isolation versus AV Node Ablation with Bi-Ventricular Pacing for Treatment of Atrial Fibrillation in Patients with Congestive Heart Failure study: compared pulmonary vein isolation with atrioventricular node ablation and biventricular pacing with an implantable cardioverter defibrillator in patients with congestive heart failure and low ejection fraction-pulmonary vein isolation was superior to atrioventricular node ablation with biventricular pacing in patients with heart failure who had refractory atrial fibrillation.

DISCERN AF study assesses the incidence and predictors of asymptomatic AF before and after catheter ablation: The ratio of asymptomatic to symptomatic AF episodes increased from 1.1 before to 3.7 after ablation, and the post ablation state was the strongest predictor of asymptomatic AF. (Verma A et al).

CABANA Trial showed that among patients with symptomatic atrial fibrillation, catheter ablation, compared with medical therapy, led to clinically important and significant improvement in the quality of life at 12 months.

Afib ablation complications

Atrial fibrillation catheter ablation complications include bleeding, pericardial complications, and stroke/TIA).

Fully 80% of procedures are done by clinicians who perform fewer than 25 AF ablations per year and in hospitals with fewer than 50 procedures per year.

The overall frequency of complications in a large study was 6.29% with cardiac complications 2.54%, vascular complications 1.53%, respiratory complications 1.3%, and neurological complications 1.02% (Deshmukh A et al),

Mortality rate with AF catheter ablation 0.46%.

Experience level of less than 25 atrial fibrillation catheter ablation procedures, and hospital volume of less than 50 procedures significantly associated with adverse outcomes.

Among patients with AF catheter ablation compared with medical therapy did not reduce death, disabling stroke, serious bleeding or cardiac arrest but did lower expected event rates (CABANA Randomized Clinical Trial).

Recurrence of atrial arrhythmias can be common despite multiple procedures.

Despite the implementation of multiple different strategies, conventional pulmonary vein isolation is the most superior technique  for the treatment of recurrent/persistent atrial fibrillation.

Among patients with atrial fibrillation and endstage heart failure, the combination of catheter ablation and medical therapy was associated with a lower likelihood of death from any cause, implantation of it left ventricular assist device or urgent  heart transplantation than medical therapy alone.

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