MELBOURNE, AUSTRALIA — To someone with a hammer, does everything look like a nail? For electrophysiologists (EPs), the saying might be amended slightly, but are those who perform catheter ablations for the treatment of atrial fibrillation more likely to recommend that patients undergo the invasive procedure?

Data from a small, single-center study suggest there might be some bias at play. In a study of five EPs working together at an academic-affiliated medical center, those who performed radiofrequency ablation were significantly more likely than their nonablationist EP colleagues to recommend ablation for patients with atrial fibrillation.

"Was this a play of chance—I don't think so," said lead investigator Dr Naseem Al-Shoaibi (McMaster University, Hamilton, ON). "The EPs who perform the ablations are comfortable with the procedure, they know exactly what they are doing, but they may be overselling the procedure a little. The nonablationist group, they appear to be a little more conservative."

Speaking here at the World Congress of Cardiology (WCC) 2014 Scientific Sessions , Al-Shoaibi presented data on 128 patients seen by the five EPs working at the tertiary clinic. Of the five EPs, three perform radiofrequency ablations while the two other EPs do not.

Of the 72 patients with AF seen by the three EPs who performed catheter ablations, 42% were referred for ablation. In contrast, just 9% of the 56 AF patients treated by the nonablationist EPs were referred for catheter ablation. As Al-Shoaibi noted during the presentation, the patient characteristics at baseline between the two groups were similar, with no statistically significant difference in age, size of the left atrium, or CHA2DS2-VASc scores.

Interestingly, all the patients referred for ablation by the nonablationist EPs had failed at least one antiarrhythmic drug, whereas 24 of the 30 (80%) referred for ablation by the ablationist EPs had failed drug therapy.

Al-Shoaibi said that catheter ablation, as per the clinical guidelines, is a second-line therapy and reserved only for patients who have failed antiarrhythmic drug therapy. Some exceptions are made in the case of young patients who present with atrial fibrillation, given that physicians worry about long-term side effects, such as significant proarrhythmic effects or possible damage to the kidney, of rhythm-control medications. "I'm not sure if there is any electrophysiologist who is very keen to keep his patients on antiarrhythmic drugs for a long time," said Al-Shoaibi.

The bottom line, though, he said, is that physician bias, even at their shared clinical center, affects clinical decision making. He would like to see the development of a patient-friendly tool that would allow patients more input into their treatment or at the very minimum provide a clearer picture of the limits of AF ablation.

Dr Bernard Gersh (Mayo Clinic, Rochester, MN), who chaired the session where the data were presented, said he was surprised by the "conservative" nature of the nonablationist EPs. That said, however, he remains nervous about multiple ablations that are often required for the treatment of AF. Gersh referred to a patient who underwent four catheter ablations for AF and who went on to develop other problems. "It's a big problem because what's being done now is taking atrial fibrillation and converting it into pulmonary hypertension," said Gersh. "I get nervous after two ablations, maybe three, but two is sort of my cutoff."

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