Pappone 25/7/08 02:40 Page 96
Arrhythmia Management
Ablation of Atrial Fibrillation
a report by
Carlo Pappone
1
and Vincenzo Santinelli
2
1. Chief, Cardiac Pacing and Electrophysiology Unit; 2. Professor of Cardiology, and Scientific Director, Arrhythmology,
San Raffaele University Hospital, Milan
Atrial fibrillation (AF) is the most common cardiac arrhythmia and is conventional ADT.
2
As a result, early ablation of subjects with AF at high risk
associated with an increased risk of morbidity and mortality.
1
Despite of progression to permanent AF may be of benefit to avoid a late procedure
important advances in its treatment, AF remains an independent predictor when AF becomes permanent. Indeed, ablation targets for permanent AF
of both morbidity and mortality. Morbidity is related to frequent are multiple: pulmonary vein (PV) isolation, vagal denervation, coronary
hospitalisations due to debilitating symptoms, heart failure (HF), stroke and sinus disconnection, roof and mitral lines and bi-atrial linear lesions. In
systemic thromboembolism. The rise in hospital admission rates for AF patients with long-lasting or permanent AF, achievement of stable sinus
among elderly patients worldwide is striking, and its cost to society is rhythm directly or by intermediate atrial tachycardia (AT) and AF/AT non-
exponentially increasing in line with the ageing of the population and the inducibility may be time-consuming, with multiple sequential lesions and
rising prevalence of risk factors. repeated procedures after the index procedure, which ultimately may be
associated with a higher risk of complications. Taken together, these
Natural History of Atrial Fibrillation in the findings emphasise the need for early ablation, possibly at the time of
Era of Catheter Ablation paroxysmal recurrent AF, to avoid rapid progression to the permanent form,
At present, there are no prospective studies on AF progression and which in patients with concomitant diseases is associated with the highest
associated risks that allow us to evaluate the potential benefits of catheter risk of morbidity and mortality.
ablation on the progression and clinical course of the arrhythmia. In an
ongoing long-term prospective study conducted from 2002 to 2007 in our At present, limited long-term data detailing the impact of catheter ablation
centre, we have observed that: of AF on morbidity are available, but there are no randomised comparative
studies on mortality in patients with AF undergoing AF ablation and ADT.
• about half of consecutive patients with first paroxysmal AF not due to One landmark non-randomised study by our group
4
reported that AF
potentially reversible causes had no further recurrences during a five-year ablation may reduce mortality compared with ADT in a large cohort of
follow-up in the absence of antiarrhythmic therapy; patients with paroxysmal (69%) or chronic (31%) AF followed up for about
• compared with patients with lone AF, those with associated diseases are three years. No cardiovascular disease was found in about one-third of
more likely to rapidly progress to permanent AF despite conventional patients, and hypertension was the most commonly associated disease. In
antiarrhythmic drug therapy (ADT); this study, survival for ablated patients was longer than that for the ADT
• age, HF and diabetes are independent predictors of progression to group, and not different from that expected for healthy persons of the
permanent AF; and same age and gender.
4
These results are important and indicate for the first
• catheter ablation may be of benefit in delaying progression to time that an ablation strategy may indeed result in a mortality benefit, thus
permanent AF over a follow-up of five years.
2,3
achieving one of the most important end-points. In fact, it is likely that
long-term maintenance of sinus rhythm after ablation in the absence of
We also demonstrated that progression from persistent to permanent AF is currently available ADT may result in a mortality benefit; this needs to be
faster than progression from recurrent paroxysmal to persistent AF despite confirmed in larger multicentre, randomised trials with a much longer
follow-up period.
Carlo Pappone is Chief of the Cardiac Pacing and
Electrophysiology Unit at the San Raffaele University
The possibility of performing catheter ablation safely in patients with HF is
Hospital, Milan. His main research interests are the an important finding. Recently, Hsu et al.
5
reported an improvement in
treatment of cardiac arrhythmias by catheter and
cardiac function among patients who had no AF recurrences after AF
electric therapies in heart failure patients. He devised a
new anatomical approach for curing circumferential
ablation. If catheter ablation is safe and results in haemodynamic
pulmonary vein ablation.
improvement, it will constitute a novel strategy for the management of
patients with both AF and HF, in whom morbidity and mortality are highest.
Vincenzo Santinelli is a Professor of Cardiology and Scientific
Director of Arrhythmology at the San Raffaele University
Catheter Ablation for Atrial Fibrillation versus
Hospital, Milan. His primary research interests include
Antiarrhythmic Drug Therapy
catheter-based treatment of cardiac arrhythmias, including
Fuelled by dissatisfaction with ADT and following the development of
atrial fibrillation ablation and electrical therapies in patients
with heart failure.
catheter-based technologies over the last decade, catheter AF ablation
has matured from an investigational technique to an effective alternative
E:
santinelli.vincenzo@hsr.it
to ADT. The impressive improvement in the results of catheter ablation in
all forms of AF compared with ADT over the last decade indicates that
96 © TOUCH BRIEFINGS 2008
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