AF ablation still has a role

I have been seeing a new trend in the AF clinic.

I never thought this would happen, but I’d estimate that at least once daily, often multiple times daily, a patient says they have read this blog before the visit. That is nice.

Many of these patients, some who have traveled across the country, or even from outside the US, say that they were drawn to my conservative approach to AF. That is also nice.

The (new) trend is that many of these patients are excellent candidates to consider ablation.

I still ablate AF. Ablation of AF has an important role. Yes, it is true that good sleep, weight loss, regular exercise, drinking less alcohol, stress reduction and control of blood pressure do wonders for atrial fibrillation; but these healthful behaviors don’t always eliminate AF.

I’m seeing patients who have symptomatic episodes, failed trials of drug treatments, and addressed their lifestyle factors, and still have symptomatic episodes of AF.

My friends, if these episodes reduce your quality of life, an ablation is reasonable. Notice I did not use the word, necessary. AF ablation is never necessary; it’s always a choice.

I’ve even seen patients with the common form of atrial flutter who have been reluctant to have ablation. Atrial flutter is much easier to ablate than AF. It may not always prevent AF from occurring. About half of patients who have flutter ablation still get AF. Half don’t. And I strongly believe that if you combine lifestyle measures after flutter ablation, the odds of AF are less. (That’s opinion, but would be a good study.)

This is not a flip-flop post.

I don’t mean to say AF ablation isn’t a big deal. It is. The procedure has not changed in 2016. We use general anesthesia; we do two trans-septal punctures; we make 50-80 burns in the left atrium of the heart; we keep patients overnight, and maddeningly, we must redo the ablation in about 20% of cases.

The treasure of AF ablation (plus lifestyle measures) is no AF. The cost is the risk. Published complication rates approach 5%. I’m proud of our complication rate; it’s about 1%. The point is it’s not zero. And the complications can be terrible–stroke, esophagus damage and perforation of the heart, for example.

I’m glad people come to see me because I’ve promoted a conservative approach, one that sees AF not as a disease, but as a symptom or sign of other diseases. It’s vital to treat the underlying causes of AF. If the atrium is under stretch (high blood pressure, obesity, sleep apnea, too much endurance exercise) or inflamed (obesity, sleep apnea, alcohol, too much exercise, lack of sleep, constant stress), it’s hardly the right idea to burn the heart.

Another reason to consider rhythm-control treatments of AF, such as ablation and drugs and cardioversions, is that it’s harder to lose weight and exercise if you don’t feel well. The holistic idea of ablation plus lifestyle measures: You get people out of AF; that improves their sense of well-being; then they are more apt to do the things that keep AF away.

An important study that I keep on the wall of my exam room is the ARREST-AF trial. In this study, Prash Sanders and Rajeev Pathek and others showed that lifestyle measures before and after the an ablation procedure increases the odds of success 5-fold.

Given the modest success rates, costs, and risks of AF ablation, it’s imperative to improve the odds of the procedure.

JMM