Europace Advance Access originally published online on April 13, 2007
Europace 2007 9(7):477-480; doi:10.1093/europace/eum048
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ATRIAL FIBRILLATION ABLATION
Contemporary catheter ablation of arrhythmias in geriatric patients: patient characteristics, distribution of arrhythmias, and outcome
1 University of Athens, Second Cardiology Department, Attikon University Hospital, Rimini 1, Haidari, 12462 Athens, Greece; 2 University of Leipzig, Heart Center, Department of Electrophysiology, Leipzig, Germany; 3 Heart Center Hirslanden, Department of Electrophysiology, Zurich, Switzerland
Manuscript submitted 20 November 2006. Accepted after revision 4 March 2007.
* Corresponding author. Tel: +30 6972727199; fax: +30 2105832351. E-mail address: nikolaosdagres{at}yahoo.de
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Abstract |
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Aims Catheter ablation is a treatment of first choice for many arrhythmias. Data in geriatric patients are still limited, mostly focusing on single arrhythmia types. The aim of the study was to investigate characteristics of contemporary ablation therapy in the very elderly, focusing on patient characteristics, arrhythmia spectrum, and outcome in a large cohort.
Methods and results We studied 131 consecutive patients aged 80 and older (mean age 83 ± 3) undergoing ablation for any indication from 1998 until 2004. Sixty-eight patients (52%) had structural heart disease. Most common indications were typical atrial flutter (54%), atrioventricular nodal re-entrant tachycardia (AVNRT) (22%), and atrial fibrillation (AF) (18%). Patients with structural heart disease had more often atrial flutter (72 vs. 35%, P < 0.001) and less AVNRT (7 vs. 38%, P < 0.001) than those without structural heart disease. In almost all patients with AF, ventricular rate control was achieved by elimination of atrioventricular conduction and pacemaker implantation. Success rate exceeded 97% for all ablation types. There was one major complication (0.8%), a stroke after isthmus ablation.
Conclusion Almost half of the very elderly patients undergoing ablation have structural heart disease. Indications have changed significantly in recent years, typical atrial flutter is nowadays the predominant indication. The arrhythmia spectrum differs significantly between patients with and without structural heart disease. Regardless of the presence or absence of structural heart disease, success is excellent. Catheter ablation is an excellent therapy option for geriatric patients with arrhythmias.
Key Words: Catheter ablation, Radiofrequency, Arrhythmia, Elderly, Geriatric
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Introduction |
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Radiofrequency catheter ablation has become a curative treatment of first choice for a broad spectrum of arrhythmias with excellent success and minimal complication rates.1
–5
Invasive therapy is frequently withheld in the very elderly. Friable cardiac structures, prone to catheter perforation, and the presence of many comorbidities are often considered to represent a special risk.6 Thus, in daily clinical practice, this very effective curative technique is less frequently applied in geriatric patients. With the rapidly growing number of these patients in the population, data on ablation in this group become increasingly important. Up to now, there are some studies on this topic4,7–9 which have reported a good ablation outcome, focusing mostly on single arrhythmia types. We investigated characteristics of contemporary radiofrequency catheter ablation in a large unselected cohort of 131 consecutive patients older than 80 years of age, focusing on patient characteristics, arrhythmia spectrum, and outcome.
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Methods |
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The study population consisted of 131 consecutive patients aged 80 and older who underwent catheter ablation for any indication from 1998 until 2004.
Written informed consent was obtained before the procedure. Radiofrequency ablation was carried out by routine techniques.10–15 In short, ablation of the inferior right atrial isthmus between tricuspid valve and inferior vena cava was performed for typical atrial flutter. Slow pathway ablation was carried out for atrioventricular nodal re-entrant tachycardia (AVNRT). For ventricular rate control in atrial fibrillation (AF) or atypical atrial flutter, we performed ablation of the atrioventricular (AV) junction, preceded by implantation of a permanent pacemaker, or AV nodal modification. Curative AF ablation for sinus rhythm restoration was performed by placement of circular lesions around the left and right pulmonary veins plus linear lesions in the left atrium. The retrograde aortic approach via the femoral artery was used for left-sided accessory pathways, right-sided pathways were approached via the femoral veins. Temperature-guided energy application was used. Patients were monitored for at least 24 h after the procedure. A 12-lead ECG was obtained before discharge.
Data are presented as mean ± SD. To evaluate differences between groups, the 
2 test or the Fisher exact test was used for categorical variables, as appropriate. A P-value < 0.05 was considered significant. Analyses were performed with the software package SigmaStat version 3.11 (Systat Software, Inc., Point Richmond, CA, USA).
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Results |
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Patient characteristics are given in Table 1. Approximately half of the patients (n = 68, i.e. 52%) had structural heart disease, mainly coronary artery disease and to a lesser extent valvular heart disease and dilated cardiomyopathy.
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Indications for ablation are listed in Table 2. Typical atrial flutter, AVNRT, and AF were the most common arrhythmias. Only a small number of patients underwent ablation for ectopic atrial tachycardia, ventricular tachycardia, and accessory pathway. The distribution of arrhythmias showed significant differences between patients with and without structural heart disease: isthmus ablation for typical atrial flutter was by far the predominant procedure in patients with structural heart disease and significantly more frequent than in those without structural heart disease (72 vs. 35%, P < 0.001). On the contrary, AVNRT was significantly more frequent in patients without structural heart disease (38 vs. 7% in patients with structural heart disease, P < 0.001) and represented together with atrial flutter, the most frequent indications for ablation in this group.
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In 31 patients (24%), the ablation procedure was the therapy of first choice. In the remaining cases, ablation was performed due to failure of antiarrhythmic therapy.
Of the 71 patients undergoing right atrial isthmus ablation for typical atrial flutter, 17 (24%) had also a history of AF before the procedure. In 11 of these 17 patients, antiarrhythmic drugs had been tried before the ablation; these were mostly (n = 8) rate control medication (digitoxin, beta-blockers, verapamil alone or in combination) and only in three cases class I or III drugs (amiodarone or propafenone alone or in combination).
A prolonged PR interval between 200 and 330 ms before the procedure was observed in six of the 29 patients undergoing slow pathway ablation for AVNRT (21%).
As shown in Table 3, success rates ranged between 97 and 100% for all procedure types. In almost all patients with AF or atypical atrial flutter, the procedure goal was ventricular rate control achieved predominantly by ablation of the AV junction and in one case by AV nodal modification. Only in one patient with AF, a curative left atrial AF ablation was performed. The patient with the accessory pathway had an inferior paraseptal pathway which was initially targeted without success from the venous side. During the same hospital stay, the patient underwent successful ablation from the arterial side.
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Complication rates for different ablation types are also listed in Table 3. Procedure-related complications were observed in five patients (3.8%). There was one major complication (0.8%), an ischaemic stroke on the second day after right atrial isthmus ablation for paroxysmal typical atrial flutter. The patient was on documented sinus rhythm during the whole hospital stay, including the time before the ablation procedure and the time after ablation up to the occurrence of the stroke. The patient was receiving aspirin 300 mg/d and was not on oral anticoagulation. Owing to the repeated documentation of sinus rhythm, no transoesophageal echocardiogram had been performed prior to the procedure. In the remaining four cases, we observed minor vascular complications. Most of them (n = 3, i.e. 2.3%) were groin haematomas treated conservatively with none requiring blood transfusion. In two of the three cases with haematomas, coronary angiography had been performed 1–2 days prior to ablation. Thus, it cannot be stated with certainty whether the haematoma was a result of the ablation or of the angiography. A pseudoaneurysm developed in one patient (0.8%) and was treated conservatively without causing further problems. Of the four patients with a vascular complication, three were on anticoagulation due to atrial flutter; anticoagulation had been temporarily interrupted prior to ablation.
At discharge, antiarrhythmic drugs were prescribed in most patients (n = 98, i.e. 75%). The great majority received beta-blockers (n = 81, i.e. 62%). This was partly due to concomitant diseases (coronary artery disease, hypertension) and in many cases did not have the purpose of antiarrhythmic medication. A beta-blocker alone was prescribed in 64 patients. Other rate control medication (digitoxin or verapamil either alone or in combination with each other or with beta-blockers) was prescribed in 25 patients (19%). A class III antiarrhythmic drug was prescribed only in nine cases (7%): amiodarone (n = 8) and sotalol (n = 1). No patient received a class I drug.
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Discussion |
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The main findings of our study can be summarized as follows. A high percentage of geriatric patients undergoing catheter ablation have structural heart disease, mainly coronary artery disease. Indications for ablation differ significantly between patients with and without structural heart disease. In the first group, typical atrial flutter dominates by far, followed by AF, whereas in patients without structural heart disease, most common indications are to an almost equal extent AVNRT and atrial flutter. In the great majority of patients with AF, the goal is ventricular rate control achieved by ablation of the AV junction; curative left atrial AF ablation is performed only in isolated cases. Overall, success rates are excellent. Complications are rare and mostly minor and can be treated conservatively.
To our knowledge, our series is the largest cohort of geriatric patients reported up to now undergoing ablation. Compared with previous reports on ablation in the very elderly,4,7 we observed a significant change in the indication spectrum. In our study population, right atrial isthmus ablation for typical atrial flutter dominated by far: in 54% in our series compared with 16% in the report of Zado et al.7 and 7% in the NASPE Registry.4 In these two previous reports, the predominant indication was AF with ablation of the AV junction. This difference is obviously attributable to the fact that isthmus ablation for atrial flutter became a widespread method mainly in the years following patient collection in the prior reports: 1996–1998 for the report of Zado et al.7 and 1998 for the NASPE Registry.4 On the other hand, the arrhythmia spectrum observed in the very elderly is markedly different than in younger patients.3,4 Indications for ablation which are common in younger populations, such as accessory pathways or ectopic atrial tachycardias, were very rare in our geriatric patients. This agrees with previous observations.4,7
Success rate in our series was excellent exceeding 97% for all ablation types. There was only one major complication, an embolic stroke after isthmus ablation. The remaining few complications were conservatively treated, minor vascular complications, mainly groin haematomas, and occurred mostly in patients with atrial flutter. This is not surprising given the fact that patients with atrial flutter are often on anticoagulation prior to ablation and anticoagulation continues following the procedure. The outcome in our series agrees with previous findings concerning efficacy and safety of ablation in the very elderly.4,7–9
A limitation of the study is the lack of follow-up data. This is especially important for patients with atrial flutter, since there is evidence for an increased risk of AF after flutter ablation in the elderly.8,16
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Conclusion |
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Catheter ablation is an excellent therapy option for geriatric patients with arrhythmias. A high percentage of geriatric patients undergoing catheter ablation have structural heart disease. The indication spectrum has changed significantly in recent years with atrial flutter being nowadays the predominant indication followed by AVNRT and AF. The arrhythmia spectrum differs significantly between patient with and without structural heart disease. In most patients with AF, ablation of the AV junction is performed for ventricular rate control. Regardless of the presence or absence of structural heart disease, success rate is excellent, complications are rare and mostly minor.
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References |
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[14] Morady F, Hasse C, Strickberger SA, Man KC, Daoud E, Bogun F, et al. Long-term follow-up after radiofrequency modification of the atrioventricular node in patients with atrial fibrillation. J Am Coll Cardiol (1997) 27:113–21.
[15] Kottkamp H, Tanner H, Kobza R, Schirdewahn P, Dorszewski A, Gerds-Li JH, et al. Time courses and quantitative analysis of atrial fibrillation episode number and duration after circular plus linear left atrial lesions: trigger elimination or substrate modification: early or delayed cure? J Am Coll Cardiol (2004) 44:869–77.
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