Managing Atrial Fibrillation

Abstract

Among the major advances in invasive electrophysiology over the last 15 years are cardiac resynchronization therapy for heart failure and ablation for atrial fibrillation (AF). Before the widespread adoption of cardiac resynchronization therapy as an approved therapy for our patients, several carefully designed trials had documented improvement in quality of life when compared with optimal medical management.1–3 Ablative therapy for AF, however, evolved as an option for patients who remained symptomatic from AF despite medical therapy. Although ablation for AF has a class IIa indication in HRS/EHRA/ECAS guidelines4 for AF management and is frequently used, pressing questions as to whether we affect patient outcomes with ablation remain. In the absence of large randomized, multicenter trials comparing ablation with drug therapy for AF, we have had to rely on relatively small, sometimes single-center, and a few recent meta-analyses of the published smaller trials on which to base our recommendations.5–7 Article see p 626 Drug therapy, a major option for AF management over the last several decades, has been recommended on the basis of well-controlled trials comparing a new drug with placebo or existing approved therapy before clinical use.8–12 What, then, are the reasons that AF ablation lacks a similar (compared with cardiac resynchronization therapy or drug therapy) evidence basis for clinical use, and what specific insights does the present well-executed meta-analysis provide?6 The meta-analysis by Piccini et al6 includes 6 trials (2 single-center) and 693 patients. The trials involve comparison of ablation with antiarrhythmic therapy and postablation follow-up for 1 year. The authors concluded that pulmonary vein isolation dramatically increased freedom from AF at 1 year when compared with nonablation treatment strategies. Before we can accept their conclusions, we must examine the difficulties inherent in performing the meta-analysis, the original trials, and, more generally, in …