Catheter Ablation of Atrial Fibrillation
A Life or Death Situation?
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See Article by Srivatsa et al
It is well known that atrial fibrillation (AF) is an independent risk factor for all-cause mortality and is also associated with an increased risk of stroke and heart failure.1,2 If these risks are indeed causal, then it would be logical that maintenance of sinus rhythm should improve mortality.
Randomized trials have sought to compare rate and rhythm control strategies with the hypothesis that patients with AF would derive a mortality benefit from maintaining sinus rhythm, but most have failed to prove this hypothesis. Previous studies comparing a rate versus rhythm control strategy using antiarrhythmic drugs, such as AFFIRM (Atrial Fibrillation Follow-Up Investigation of Rhythm Management), RACE (Rate Control Versus Electrical Cardioversion), and STAF (Strategies of Treatment of Atrial Fibrillation)3–5 failed to show a reduction in stroke and mortality with a rhythm control strategy and at most demonstrated an improvement in symptoms and quality of life.6–8 Explanations for these results have included that the benefit of sinus rhythm may be offset by the harmful effects of antiarrhythmic drugs (particularly amiodarone); the percentage of patients maintaining sinus rhythm with medical rhythm control is low; and the relationship of AF and mortality may be associative and not causative. It should be noted, however, that a substudy of AFFIRM did demonstrate reduce mortality in those patients who actually maintained sinus rhythm regardless of their randomized strategy.9
In recent years, several randomized trials have shown that catheter ablation is superior to antiarrhythmic drugs to maintain sinus rhythm.10,11 If part of the benefit of sinus rhythm is being undermined by the toxicities of antiarrhythmics, then it would be logical to retest the hypothesis that rhythm control could benefit mortality through the use of ablation. The major limitation …