Ablation Therapy for Atrial Fibrillation: What's Your AQ?

The conceptual foundation for the development of catheter ablation of atrial fibrillation (AF) was established more than 15 years ago after the observation that foci of ectopic beats that originated from the pulmonary veins could trigger the arrhythmia. It is now an essential modality for patients with AF, supported by evidence from several large prospective randomized trials showing that catheter ablation may in some patients be superior to antiarrhythmics for AF control. See what you know about this treatment for the tachyarrhythmia that now affects more than 1% of the general population.

1. Atrial fibrillation (AF) ablation should only be used as a “last resort” in management of the arrhythmia.

A. True

B. False

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Answer: B. False   

Cardiac ablation is emerging as one of the most effective treatments for maintaining sinus rhythm in AF especially for those patients who are highly symptomatic. This therapy is now being recommended earlier and earlier in the course of “paroxysmal” AF, before it has time to progress to “persistent” or “permanent” AF. Yet, registry data shows that AF ablation continues to be underutilized, while pacemaker implantation and atrioventricular nodal implantation may be overutilized.

2. Atrial fibrillation ablation involves which of the following?

A. Transseptal puncture

B. Pulmonary vein isolation

C. Left atrial appendage isolation

D. A and B

E. B and C

F. All of the above

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Answer:  D. A (transseptal puncture) and B (pulmonary vein isolation)

To access the left atrium (which is the source of the majority of AF trigger sites and rotors), right heart access is obtained and a transseptal puncture is made in the interatrial septum. Once the left atrium is entered, the pulmonary veins are electrically isolated with catheter ablation. This is the most common method of atrial fibrillation ablation but success rates remain dismal (58.7% success rate at 12 years). The left atrial appendage is a novel ablation site shown to have some success in increasing the freedom from AF recurrence.

3. Which of the following factor(s) is/are associated with recurrence of AF following ablation?

A. Age >64y

B. Left atrial diameter

C. Female sex

D. BMI ≥30 kg/m²

E. None of the above

F. All of the above

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Answer: F. All of the above. 

Increasingly, newer triggers are being identified in recurrence of atrial fibrillation after ablation. All of these factors have been known to play a role in recurrence of AF after extended pulmonary vein isolation.
 

Sources:

Alipour A, Swaans MJ, van Dijk VF, et al. Ablation for atrial fibrillation combined with left atrial appendage closure. JACCCEP. 2015;1:486-495. doi:10.1016/j.jacep.2015.07.009.

Camm AJ, Lip GY, De Caterina R, et al. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J. 2012;33:2719-2747.

Haegelj LM, Calkins H. Catheter ablation of atrial fibrillation: an update. Eur Heart J. DOI: http://dx.doi.org/10.1093/eurheartj/ehu291 ehu291 First published online: 22 July 2014.

January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation. 2014;130:2071-104.

Kumar S, Michaud GF. Catheter ablation for paraoxysmal atrial fibrillation: time to focus more on trigger ablation? Circulation: Arrhythm  Electrophysiol. 2016; 9: e004129.  doi: 10.1161/CIRCEP.116.004129