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Understanding the Expert Consensus Recommendations on Catheter and Surgical Ablation of Atrial Fibrillation: Atrial Fibrillation Ablation: A First-Line Therapy?


Atrial Fibrillation Ablation: A First-Line Therapy?

Medscape: The Consensus Statement makes it clear that AF ablation, as is currently performed, should not be considered as a first-line therapy in most patients. Why did the Task Force reach this conclusion at this time?

Dr. Calkins: This conclusion was reached in recognition of 2 things. First, it is an acknowledgment of the fact that the procedure has very significant risks, a 2%-6% major complication rate -- even higher in some literature. And some of the complications are lethal. If a physician does an AF ablation as a first-line treatment in a 35-year-old patient, and an esophageal fistula develops and the patient dies, the physician is going to feel pretty bad about that. They will wonder why they didn't try a drug first. So this is an acknowledgment that with this procedure, death and stroke are both very real complications. I'm not saying they are common complications, but they certainly have occurred and continue to occur, and we don't have all the answers on how to prevent them.

Second, this is an acknowledgment that AF ablation is an emerging field and the procedure keeps getting better. The issue right now is not which is better, catheter ablation or drugs, for the rest of the patient's life, the question is, for the next year or two as AF ablation gets better with new technologies and new tools, which is better? Is it better for the patient's AF to be controlled with an antiarrhythmic drug or is it better for the patient to have a procedure that's still evolving? I think that most of us on the committee felt that if a patient responds to a drug and the ablation procedure can be delayed for several years, that's a good thing, because the procedure they will end up receiving is probably going to be different from the one we're doing now, and it's probably going to be safer and more effective.

It's also important to note that we did say in the document that in certain situations it may be appropriate to do AF ablation as first-line therapy. The point is that the physician needs to explain to the patient what the standard of care is, and if the patient wants other than the standard of care -- that is if they want to do catheter ablation as a first-line therapy -- they need to be aware that they're taking an aggressive approach. They need to understand that approach may not be wrong, but it's not considered standard for most patients, it's the exception, not the rule.

Medscape: Do you think that this recommendation on first-line therapy will change as the technology and experience evolve?

Dr. Calkins: Yes. We have achieved 95%+ success and less than 1% risk of major complications for other procedures, such as PSVT [paroxysmal supraventricular tachycardia], and if we ever get to that level of efficacy and safety with AF ablation, absolutely this will be first-line therapy.

Medscape: Was the question of first-line therapy an area of contention among Task Force participants?

Dr. Calkins: All of these questions were put to a strict, anonymous vote and the consensus was established. But there some members of the Task Force that really pushed hard for a green light in selected patients to do AF ablation as a first-line therapy, and I think there's enough data out there to suggest that's reasonable. But, again, hopefully those procedures will be performed at experienced centers and in carefully selected patients.

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