Ablation Versus Drugs: What Is the Best First-Line Therapy for Paroxysmal Atrial Fibrillation?

Biase, Luigi Di

doi:10.1161/circep.113.000629

Cited by 22 publications

(8 citation statements)

References 47 publications

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“…Current guidelines for AF management recommend AADs as the first-line therapy [ 11 , 19 , 22 – 25 ]. The 12-month AF recurrence rate for patients treated with AADs ranges from 24 to 63% [ 11 , 22 , 25 ]. Among drug refractory AF patients, catheter ablation is the recommended treatment option [ 19 ].…”

Section: Discussionmentioning

confidence: 99%

Resource use and clinical outcomes in patients with atrial fibrillation with ablation versus antiarrhythmic drug treatment

Jarman

Hussain

Wong

et al. 2018

BMC Cardiovasc Disord

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BackgroundThe objective of our study was to compare resource use and clinical outcomes among atrial fibrillation (AF) patients who underwent catheter ablation versus antiarrhythmic drug (AAD) treatment.MethodsA retrospective cohort design using the Clinical Practice Research Data-Hospital Episode Statistics linkage data from England (2008–2013) was used. Patients undergoing catheter ablation treatment for AF were indexed to the date of first procedure. AAD patients with at least two different AAD drugs were indexed to the first fill of the second AAD. Patients were matched using 1:1 propensity matching. Primary endpoints including inpatient and outpatient visits were compared between ablation and AAD cohorts in the 4 months-1 year period after index. Secondary endpoints including heart failure, stroke, cardioversion, mortality, and a composite outcome were compared for the 4 months-3 years post-index period in the two groups. Cox-proportional hazards models were estimated for clinical outcomes comparison.ResultsA total of 558 patients were matched in the two groups for resource utilization comparison. The average number of cardiovascular (CV)-related outpatient visits in the 4–12 months post-index period were significantly lower in the ablation group versus the AAD group (1.76 vs 3.57, p < .0001). There was no significant difference in all-cause and CV-related inpatient visits and all-cause outpatient visits among the two groups. For secondary endpoints comparison, 615 matched patients in each group emerged. Ablation patients had 38% lower risk of heart failure (hazard ratio [HR] 0.62, p = 0.0318), 50% lower risk of mortality (HR 0.50, p = 0.0082), and 43% lower risk of experiencing a composite outcome (HR 0.57, p = 0.0009) as compared to AAD treatment cohort.ConclusionAF ablation was associated with significantly lower CV-related outpatient visits, and lower risk of heart failure and mortality versus AAD therapy.

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Section: Discussionmentioning

confidence: 99%

Resource use and clinical outcomes in patients with atrial fibrillation with ablation versus antiarrhythmic drug treatment

Jarman

Hussain

Wong

et al. 2018

BMC Cardiovasc Disord

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“…Ablation of cardiac tissue is an important treatment of cardiac arrhythmias, especially atrial fibrillation [ 1 , 2 ]. Currently, ablation is done by either heating tissue with RF currents or cooling it, but both thermal methods have important limitations, in particular high recurrence rates [ 3 , 4 ], significant complication rates [ 5 , 6 ], and long procedure times [ 7 , 8 ].…”

Section: Introductionmentioning

confidence: 99%

Effect of Twisted Fiber Anisotropy in Cardiac Tissue on Ablation with Pulsed Electric Fields

Xie

Zemlin

2016

PLoS ONE

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BackgroundAblation of cardiac tissue with pulsed electric fields is a promising alternative to current thermal ablation methods, and it critically depends on the electric field distribution in the heart.MethodsWe developed a model that incorporates the twisted anisotropy of cardiac tissue and computed the electric field distribution in the tissue. We also performed experiments in rabbit ventricles to validate our model. We find that the model agrees well with the experimentally determined ablation volume if we assume that all tissue that is exposed to a field greater than 3 kV/cm is ablated. In our numerical analysis, we considered how tissue thickness, degree of anisotropy, and electrode configuration affect the geometry of the ablated volume. We considered two electrode configurations: two parallel needles inserted into the myocardium (“penetrating needles” configuration) and one circular electrode each on epi- and endocardium, opposing each other (“epi-endo” configuration).ResultsFor thick tissues (10 mm) and moderate anisotropy ratio (a = 2), we find that the geometry of the ablated volume is almost unaffected by twisted anisotropy, i.e. it is approximately translationally symmetric from epi- to endocardium, for both electrode configurations. Higher anisotropy ratio (a = 10) leads to substantial variation in ablation width across the wall; these variations were more pronounced for the penetrating needle configuration than for the epi-endo configuration.For thinner tissues (4 mm, typical for human atria) and higher anisotropy ratio (a = 10), the epi-endo configuration yielded approximately translationally symmetric ablation volumes, while the penetrating electrodes configuration was much more sensitive to fiber twist.ConclusionsThese results suggest that the epi-endo configuration will be reliable for ablation of atrial fibrillation, independently of fiber orientation, while the penetrating electrode configuration may experience problems when the fiber orientation is not consistent across the atrial wall.

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“…Although ablation was initially reserved for severe cases of AF that did not respond to other approaches, the success of ablation relative to other options in preventing AF recurrence has led to a rapid increase in its use across the spectrum of AF patients. (Santangeli et al, 2014; Wright and Narayan, 2015) While AF ablation can in many cases restore normal conduction patterns, reducing the risk of stroke and other complications, there is emerging evidence that ablation can significantly impair long-term atrial mechanical function (Cochet et al, 2014) and induce other complications such as asymptomatic cerebral embolism. (Haines, 2013) Accordingly, the question of how to balance trade-offs between the risks and benefits when deciding when to perform ablation and how much damage to induce in individual patients is an important topic of active research and discussion.…”

Section: Ablation Of Atrial Fibrillationmentioning

confidence: 99%

Making better scar: Emerging approaches for modifying mechanical and electrical properties following infarction and ablation

Holmes

Laksman

Gepstein

2016

Progress in Biophysics and Molecular Biology

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Following myocardial infarction (MI), damaged myocytes are replaced by collagenous scar tissue, which serves an important mechanical function – maintaining integrity of the heart wall against enormous mechanical forces – but also disrupts electrical function as structural and electrical remodeling in the infarct and borderzone predispose to re-entry and ventricular tachycardia. Novel emerging regenerative approaches aim to replace this scar tissue with viable myocytes. Yet an alternative strategy of therapeutically modifying selected scar properties may also prove important, and in some cases may offer similar benefits with lower risk or regulatory complexity. Here, we review potential goals for such modifications as well as recent proof-of-concept studies employing specific modifications, including gene therapy to locally increase conduction velocity or prolong the refractory period in and around the infarct scar, and modification of scar anisotropy to improve regional mechanics and pump function. Another advantage of scar modification techniques is that they have applications well beyond MI. In particular, ablation treats electrical abnormalities of the heart by intentionally generating scar to block aberrant conduction pathways. Yet in diseases such as atrial fibrillation (AF) where ablation can be extensive, treating the electrical disorder can significantly impair mechanical function. Creating smaller, denser scars that more effectively block conduction, and choosing the location of those lesions by balancing their electrical and mechanical impacts, could significantly improve outcomes for AF patients. We review some recent advances in this area, including the use of computational models to predict the mechanical effects of specific lesion sets and gene therapy for functional ablation. Overall, emerging techniques for modifying scar properties represents a potentially important important set of tools for improving patient outcomes across a range of heart diseases, whether used in place of or as an adjunct to regenerative approaches.

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Ablation Versus Drugs: What Is the Best First-Line Therapy for Paroxysmal Atrial Fibrillation?

Abstract: We adapted a systematic review protocol developed by the Cochrane collaboration 23 and previously published by our group.

Cited by 22 publications

References 47 publications

Resource use and clinical outcomes in patients with atrial fibrillation with ablation versus antiarrhythmic drug treatment

Resource use and clinical outcomes in patients with atrial fibrillation with ablation versus antiarrhythmic drug treatment

Effect of Twisted Fiber Anisotropy in Cardiac Tissue on Ablation with Pulsed Electric Fields

Making better scar: Emerging approaches for modifying mechanical and electrical properties following infarction and ablation

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