Europace Advance Access originally published online on June 3, 2009
Europace 2009 11(8):1002-1003; doi:10.1093/europace/eup128
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EP WIRE
Validation of success following atrial fibrillation ablation: a European survey
1 Centre Médico-Chirurgical Parly 2, 21, rue Moxouris, 78150 Le Chesnay, France; 2 Leiden University Medical Center, Leiden, The Netherlands
* Corresponding author. Tel: +33 139238619; fax: +33 139238618. E-mail address: franck.halimi{at}club-internet.fr
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Abstract |
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This survey sampled the follow-up (FU) strategies for atrial fibrillation ablation used by electrophysiology/ablation centres in Europe. Currently, FU relies on symptoms and short-term ECG recordings rather than monitoring by implantable devices. The responding centres show a lack of confidence in the long-term success after ablation, and confusion about definition of success which needs to be informed by updated European guidelines.
Key Words: Atrial fibrillation, Catheter ablation, Monitoring, Holter
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Introduction |
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Catheter ablation has become an important treatment modality in recurrent symptomatic atrial fibrillation (AF).1
However, there is neither a clear definition of what constitutes a successful ablation procedure nor agreement on the follow-up (FU) strategies. This survey sampled among electrophysiology centres, European practices in the field of AF ablation, and can inform further discussion on studies that are needed to guide development of future clinical practice. |
Results |
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Thirty-three of the European centres, members of the SIC network, answered an electronic questionnaire on FU strategies after AF ablation in March 2009 on the European Heart Rhythm Association website. Responses to this survey came from centres with a range of procedural volume: performing <50 to >300 AF ablation procedures per year (<50: 36.4%, 50–100: 18.2%, 100–300: 33.3%, and >300: 12.1%). Confirmation of the absence of AF recurrence during the first year of FU is essentially based on the absence of clinical symptoms, intermittent clinical FUs with standard surface ECG recording, and sometimes external ambulatory monitoring, but infrequently using pacemaker/defibrillator memories or implantable loop recorders (Figure 1). However, there appears to be increasing enthusiasm for the use of implantable devices in FU which could become the ‘gold standard’ to validate success for two-thirds (yes: 30.3% and may be: 36.4%). Anticoagulation discontinuation in a patient with occasional AF recurrences, independently of symptoms, seems reasonable for the majority if the CHADS2 score is <2 (90.9%), but never if the CHADS2 score is greater (0%). For 69.7% of the responding centres, success should be defined as documented total freedom from AF without the use of antiarrhythmic drugs. However, most centres (81.8%) also felt a need to differentiate electrical success (no AF recurrence) and clinical success (disappearance of symptoms), and 57.6% felt that success definition should be modulated according to the type of AF (paroxysmal/persistent/permanent). Success rate in the literature is believed to be overestimated by 100% of responders, and the great majority (87.9%) thinks that rigorous definitions of procedural success should be developed and defined through European trials and guidelines.
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Discussion |
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Clinical studies have demonstrated the high incidence of asymptomatic AF episodes as well as the reduction of symptoms in patients on antiarrhythmic drugs and following AF ablation.2
–4 Therefore, validation of success after AF ablation cannot rely on the absence of clinical symptoms but should be assessed by intermittent and prolonged ECG recordings (standard or trans-telephonic ECGs, external ambulatory recordings, implantable loop recorders, and pacemaker or defibrillator memories). Indeed, more thorough and rigorous monitoring will lead to more AF detection and will greatly influence success rate in our centres as well as in published series.5 This survey was designed to give a snapshot of European FU strategies following AF ablation and to understand what pragmatic definition of ablation success is currently used in European clinical practice. Thus, for the moment, FU appears to be based only on the absence of clinical symptoms and on intermittent or short-term ECG recordings such as Holter monitoring. Pacemaker and defibrillator memories may be used when the device is already implanted, but few are willing to implant a loop recorder post-operatively to confirm longer term success. This may indicate the need to develop new external tools to validate long-term results or improved more cost effective implantable recorders/technologies. Consideration of anticoagulation discontinuation stresses that this issue is not related to what we define as ‘success’, but only to the CHADS2 score. Perhaps surprisingly, there appears to be no real confidence in the long-term success after ablation due to the natural history of AF recurrence. The key issue appears to be the definition of success itself: electrical or clinical; with or without drugs; the same for each type of AF? The responses show a gap between the theoretical electrical definition of success based on a total freedom from AF recurrence without antiarrhythmic drugs and the need to define a clinical success based on disappearance of symptoms. Electrical success does not appear as the only endpoint in clinical practice, especially if success definition is modulated according to AF type. Total freedom from symptoms after ablation of a patient with paroxysmal AF and a CHADS2 score <2 could be an acceptable clinical target, and could also allow discontinuation of antiarrhythmic drugs and anticoagulation. Survey responses show an enormous lack of confidence in the success rates published in the literature, due to different definitions of success and differing FU strategies, and there is an urgent need for clarification. These issues should be informed, in the future, by definitive European trials and updated guidelines together with the development of new long-term monitoring tools.
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Acknowledgements |
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Thanks to Marie-Christine Villard and Verity Savidge for their active support.
Conflict of interest: none declared.
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References |
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[1] Jaïs P, Cauchemez B, Macle L, Daoud E, Khairy P, Subbiah R, et al. Catheter ablation versus antiarrhythmic drugs for atrial fibrillation: the A4 study. Circulation (2008) 118:2498–505.
[2] Page RL, Wilkinson WE, Clair WK, McCarthy EA, Pritchett EL. Asymptomatic arrhythmias in patients with symptomatic paroxysmal atrial fibrillation and paroxysmal supraventricular tachycardia. Circulation (1994) 89:224–7.
[3] Patten M, Maas R, Karim A, Müller HW, Simonossky R, Meinertz T. Event-recorder monitoring in the diagnosis of atrial fibrillation in symptomatic patients: subanalysis of the SOPAT trial. J Cardiovasc Electrophysiol (2006) 17:1216–20.[CrossRef][Web of Science][Medline]
[4] Hindricks G, Piorkowski C, Tanner H, Kobza R, Gerds-Li JH, Carbucicchio C, et al. Perception of atrial fibrillation before and after radiofrequency catheter ablation: relevance of asymptomatic arrhythmia recurrence. Circulation (2005) 112:307–13.
[5] Arya A, Piorkowski C, Sommer P, Kottkamp H, Hindricks G. Clinical implications of various follow up strategies after catheter ablation of atrial fibrillation. Pacing Clin Electrophysiol (2007) 30:458–62.[CrossRef][Medline]
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