COMMENTARY

When Should Patients With AF Undergo Ablation?

An Interview With Luigi Di Biase

Ileana L. Piña, MD, MPH; Luigi Di Biase, MD, PhD

Disclosures

November 07, 2016

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Ileana L. Piña, MD, MPH: Hi. This is Ileana Piña from Montefiore Medical Center and Albert Einstein College of Medicine in the Bronx, New York. I am at the European Society of Cardiology 2016 meeting, which has drawn about 34,000 attendees. That makes it the largest cardiology meeting in the world. Many exciting things have happened at this meeting, including the release of the European atrial fibrillation guidelines.

I am very happy to have one of my own colleagues here today. Dr Luigi Di Biase is director of the electrophysiology section in the Division of Cardiology at Montefiore Medical Center, and a electrophysiologist who is well-known worldwide and who has high expertise in ablation. Luigi, welcome. Thank you for chatting with me today.

Luigi Di Biase, MD, PhD: Thank you very much, Ileana, for the invitation and the opportunity.

Dr Piña: The new European atrial fibrillation guidelines[1] talk about ablation. You do this every day at our hospital. Perhaps our Medscape audience would like to hear your view of ablation and who should undergo ablation.

Dr Di Biase: In these newly released guidelines from the European Society of Cardiology, they moved toward more ablation of atrial fibrillation. This is clearly shown if you take a deep look into the guidelines. Indeed, the indication for ablation for patients with persistent atrial fibrillation is now wider than before.

This istypical of what we see every day. More and more patients are being sent to undergo ablation. I believe there is no doubt that in patients with paroxysmal atrial fibrillation and a normal heart, ablation plays a role even before the antiarrhythmic drugs fail. The guidelines now say you can do it, and of course, you also need the will of the patient to undergo ablation. But certainly, after the failure of at least one antiarrhythmic drug, ablation is the strategy that will allow the best path to achieve freedom from atrial fibrillation and rhythm control.

Ablation Success Rates

Dr Piña: What is your success rate with ablations?

 
The patient who responds to PVI alone is the patient with paroxysmal atrial fibrillation, a normal heart, and no or very little comorbidity.
 

Dr Di Biase: It depends on the patient and the cause of the atrial fibrillation. In research I have conducted in recent years, I have found that atrial fibrillation comes from the pulmonary veins (PVs) and also comes from non-PV triggers. The patient who responds to pulmonary vein isolation (PVI) alone is the patient with paroxysmal atrial fibrillation, a normal heart, and no or very little comorbidity. If the patient has sleep apnea, is obese, or is over 70 years old; has left ventricular dysfunction; or has heart failure, these patients do not respond to PVI alone. Then you need to do a more extensive ablation, which in our view includes ablation to non-PV triggers. These non-PV triggers are often located into the coronary sinus, the superior vena cava, and the posterior wall of the left atria.

Dr Piña: So both atria can be involved?

Dr Di Biase: Both atria can be involved, but the posterior wall, the roof, and the coronary sinus are the major targets for non-PV triggers. In patients with long-standing, persistent atrial fibrillation, it is very important to isolate the left atrial appendage.

I presented results of a randomized trial[2] last year at the European Society of Cardiology meeting that will be published in the Journal of American College of Cardiology. In this trial, we randomly assigned patients with long-standing persistent atrial fibrillation to undergo ablation with or without empirical isolation of the left atrial appendage. The patients who underwent empirical isolation of the atrial appendage had better outcomes.

Thus, in addition to PVI, specific patients require intervention to more than the pulmonary vein. If I limit my procedure to pulmonary vein isolation in patients who have sleep apnea, my success rate is low. But if I address more potential triggers, my success rate is high.

Dr Piña: So patient selection is very important.

Dr Di Biase: It is very important, and the technique for ablation is very important. I would say the success rate is around 70% in patients with paroxysmal atrial fibrillation, with one procedure. The rate is 65%-70% with two procedures in patients with persistent atrial fibrillation.

Drug Therapy After Ablation

Dr Piña: In patients who have had successful ablation, what do you do with their drug therapy?

Dr Di Biase: I have a very strict protocol. During the 3 months postablation—which we call the "blanking period," when the heart is "irritated" by the ablation—I typically put the patient on a previously ineffective drug, which is usually a class 1C antiarrhythmic drug.

Dr Piña: A beta-blocker?

Dr Di Biase: A beta-blocker, or a class 1C drug, if the patent was on amiodarone, for example. I would finish the 3 months with that medication. Then, I stop the previously ineffective antiarrhythmic, and follow the patient with intense monitoring. I usually use the ZIO® Patch (iRhythm Technologies, Inc; San Francisco, California), or 14 days of Holter monitoring. I check them continuously to look for recurrence.

Dr Piña: But amiodarone is going to stay in the system for weeks.

Dr Di Biase: Yes. You must wait at least 3-6 months after ablation, until the amiodarone is completely out of the system, to find out whether your procedure was successful or not.

Dr Piña: What do you do with anticoagulation during and after the ablation?

Dr Di Biase: We have published randomized trials[3,4] on this issue. For anticoagulation during the ablation, we do not stop the anticoagulation with warfarin; we perform the procedure within a therapeutic range of anticoagulation. We also never stop the anticoagulation with a novel oral anticoagulant (NOAC).

Dr Piña: You do not stop anticoagulation.

Dr Di Biase: We do not stop it. The patient takes it the night before, or even the morning of, the procedure.

Dr Piña: Do you continue the anticoagulant because of the risk for stroke during that period?

Dr Di Biase: Yes. Periprocedural stroke is a problem, and bridging with low-molecular-weight heparin increases the risk for bleeding and groin hematoma.

Dr Piña: Especially in women, correct?

Dr Di Biase: Especially in women. As you know, the anatomy of the groin axis is different in women than in men. So female sex is also a consideration when dealing with complications.

CABANA Trial

Dr Piña: You were part of the CABANA (Catheter Ablation vs Antiarrhythmic Drug Therapy for Atrial Fibrillation) study. Tell us about this. We have talked a bit about the CABANA trial on this blog. What is going on with the trial?

 
Everyone can prescribe antiarrhythmic drugs, but not everyone can perform the ablation in the same way.
 

Dr Di Biase: CABANA is fully enrolled. We are at the follow-up stage, at this point.

Dr Piña: How long is the follow-up?

Dr Di Biase: The preliminary data will be released after 2 or 3 years of follow up. Thus, we will have the preliminary data out in about 2 more years.

Why is this trial important? This is the first trial that is looking not at the outcome of freedom from atrial fibrillation, between rate control and rhythm control, but at the primary endpoint of mortality. We want to know whether patients who undergo ablation have the same or lower mortality compared with patients who do not undergo ablation but are treated with antiarrhythmic drugs.

Dr Piña: That is a very important trial.

Dr Di Biase: Unfortunately, the success of this procedure depends on the experience of the interventionist. So the trial is jeopardized by this. Everyone can prescribe antiarrhythmic drugs, but not everyone can perform the ablation in the same way. Thus, this may be recognized as a limitation of the trial or as an advantage of the trial, because we want it to reflect reality.

Medicine is not magic. Medicine should be something that can be reproduced by others, in my view. Thus, it is important that the trial have wide variability.

Dr Piña: What is your advice to the general cardiologist? In a patient with new atrial fibrillation, should they try antiarrhythmic therapy first?

Dr Di Biase: If the patient is young and is having numerous episodes of atrial fibrillation, even paroxysmal atrial fibrillation, and has undergone one cardioversion, I believe ablation should be offered. I believe it could be offered even as first-line therapy. In patients with persistent atrial fibrillation, the patient should be offered ablation after the failure of one or possibly two antiarrhythmic drugs. I would not recommend amiodarone for long-term use because of the side effects.

I also would not recommend that the patient be in atrial fibrillation for many years, because the heart may then be susceptible to tachycardia-induced cardiomyopathy—tachycardiomyopathy. When general cardiologists compare antiarrhythmic drugs and ablation, they usually say the ablation has some procedural risk. But I would like the general cardiologist to see that antiarrhythmic drugs also have side effects. And that the side effects do not happen the day we prescribe the drug.

Dr Piña: They happen further down the line.

Dr Di Biase: But this does not mean that we are not responsible for them.

Age is another factor that needs to be considered, and I discuss this with my patients. Today, at age 55 years, my antiarrhythmic drug is working properly. In 20 years, I will be 75 and my kidneys and liver will be older. When I am 75, will my kidneys and liver be able to tolerate the drug in the same way as now? I do not think so. I will be older; I will not have uncontrolled atrial fibrillation. At that time, my procedure will be more dangerous, possibly with more complications.

Dr Piña: Yes. And you may not be able to tolerate the anticoagulants as well, either.

Dr Di Biase: My idea is to treat atrial fibrillation as you would treat cancer: Prevent the atrial fibrillation from evolving into a more dangerous condition.

Dr Piña: By the way, one of the things that I like about these new guidelines is that when they talk about the patient with heart failure, they discuss the importance of good medical therapy to prevent atrial stretch. We know that in patients with heart failure with preserved ejection fraction (HFpEF), we have a problem with atrial stretch. And those patients are difficult to control.

Dr Di Biase: Actually, I believe that patients with heart failure and atrial fibrillation, if they are in good clinical condition, can undergo the procedure. I believe ablation plays a big role here. In these patients, we are limited with antiarrhythmic drugs because the only drug we have is amiodarone.

Dr Piña: Or a beta-blocker.

Dr Di Biase: But sometimes that is not enough. That is why I believe ablation can play a big role in patients with heart failure. Sometimes, when a patient undergoes cardiac resynchronization therapy (CRT), the atrial fibrillation can interfere and the CRT does not work. We know that ablation is for atrial fibrillation and that it plays a bigger role, because it also can improve the patient's symptoms. This is what the CABANA trial will tell us.

There are at least three big registries that have shown that patients undergoing ablation have fewer strokes and lower mortality than patients who do not undergo ablation. One of these was published recently in the European Heart Journal[5]: a Swedish registry that included about 15,000 patients, And from their registry, it came out that patients undergoing ablation have a risk for mortality and stroke similar to that in patients without atrial fibrillation, and better than that in the patients who had atrial fibrillation and were treated with antiarrhythmic drugs. These data are available now and are very important. Another series from Bunch and colleagues[6] in Utah found similar outcomes in the United States.

Dr Piña: So, there seems to be some consistency.

Dr Di Biase: I believe that the CABANA trial results also will be consistent with these data. I believe I see this in daily practice.

Dr Piña: Thank you so much for joining me today. I hope our audience has benefited from listening to this.

One good piece of advice is that if you have questions about your patients, call your electrophysiologists, and learn about their techniques and approaches before you make a decision. Just as important and also in the guidelines, involve the patient when you treat atrial fibrillation, just as we do for patients with heart failure. Use the team approach, where you have multiple specialties working together.

This is Ileana Piña. Thank you for joining me today. I hope this discussion will be helpful to your practice and your patients. Have a great day.

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