Recent news in AF ablation

Only a few days had passed before the emails began arriving in earnest.

The recently reported study in the Journal of the American College of Cardiology revealed “sobering” long-term results in atrial fibrillation ablation. That the seemingly negative results came from the highly-respected AF-ablation center in Bordeaux, France, made it more newsworthy.

On first glance the Bordeaux report looks dismal.  They report a five-year AF-free survival of only 29%.  Additionally, they also add that recurrences continue to occur after one year at a rate of about 9% per year.  So, unlike other ablation procedures, getting through an initial post-procedure period without recurrent AF does not necessarily portend long-term success.

But it’s not as bad it seems.

In fact, it’s ironic that this study is released at a time when—in the real-world–AF-ablation is rocking.  We are doing much better. So much better in fact that I was planning a new update. I was going to report good things like:

• Procedure times are often less than two hours for paroxysmal and re-do cases, and about 3 hours for persistent AF cases.
• X-ray times are almost always less than 30 minutes; frequently they are less than 20 minutes.
• Complications occur less often; though I hesitate to brag because—like most EP doctors—I am superstitious.
• Since we have done AF ablation for years, we have a better feel.  For instance, more experience brings unmeasurable nuances like knowing that an area needs more (or less) attention in the first procedure.
• Our success rates are better.  We see fewer outright failures.  In my experience, nearly all patients who have AF-ablation—as Dr Hugh Caulkins referred to in this well publicized interview on The Heart.org—are improved.  Patients may need more than one procedure, or they may still require a drug, or their episodes are markedly reduced, not gone, but yet the net result is that they feel better.  This is different than it was years ago.

That’s great, you might say, but the Bordeaux guys are surely better than you, and it doesn’t look like they are doing very well.  What gives?

As it is always, the details of the paper are important.  For instance:

• The highly publicized modest success rates were those after only one procedure. If one reads further, to the success rates after the “last” procedure (50% had two; 20% had three or more procedures), their results are in line with present-day quotes of 80% overall success–though this drops to 63% at five years.
• Their data comes from a cohort of just 100 patients done in 2001-2002.  That’s only a year or so after their initial report of AF ablation.  Why report on such a pre-historic patient cohort?  And if you do, why not add a comparison cohort of a similar 100 patients from 2005-2006?  My guess is that the latter group would have fared better.
• More than a third of their patients (37%) had advanced AF—a more difficult group to ablate.
• In 2001-2002 ablation was done differently.  As the authors point out, ablation is now directed farther from the origin of the pulmonary veins.  This strategy incorporates more of the left atrium and thus enhances the chance of success.
• In 2001-2002 they did not have the benefit of the routinely-used 3D mapping systems of today.  All AF-ablators would agree that these systems are exceedingly helpful, if not necessary for successful AF ablation.

Even with these caveats this is an important trial. It keeps us grounded.

It strongly reinforces two notions about AF that deserve emphasis: that AF is a complex diverse disease, and that, though ablation can be an effective means for relieving symptoms, it is far from a cure.

In treating AF, we have come a long way but have much farther to go.

JMM

P.S. I am still searching for a reason why they published a 100 patient (of thousands) cohort from so long ago.  I don’t know them personally, but in the past, when AF ablation was falsely seen as a panacea, the Bordeaux group always offered a steadying voice of reason.  Perhaps, they see themselves as caretakers of AF ablation.  It was their baby, and now, as a protective parent would, they feel the need to watch over their creation. I am glad they are.  Too bad they didn’t discover the ICD.