Treatment for atrial fibrillation: drugs or ablation?
10 September 2009
Atrial fibrillation ablation is one of the fastest growing techniques
in cardiology and due to the very high number of patients that might be
candidates to this procedure, a significant number of resources will
have to be devoted to it to be able to treat them in the following
Atrial Fibrillation (AF) is the most frequent cardiac arrhythmia. Its
prevalence increases with age affecting more than 5% of the population
older than 75 years of age. Overall it is estimated that more than
3.000.000 patients in Europe suffer from atrial fibrillation. Atrial
fibrillation doubles the possibility of death mainly due to the higher
incidence of thromboembolic events and occurrence of heart failure in
patients suffering this arrhythmia.
One treatment objective is directed to avoid the negative
consequences of the arrhythmia by trying to maintain normal sinus
rhythm. Two strategies exist to obtain this result:
1. Chronic treatment with antiarrhythmic drugs (AAD).
AAD treatment tries to block or modulate the
electrical activity of the heart avoiding initiation and perpetuation of
the arrhythmia. It is effective in about 60% of patients and requires
long-term treatment. Many of the drugs used have side effects, some of
them disabling for the patient. Many drugs are available and combination
of them might be used in case of failure. Compliance of the treatment is
basic for long-term success.
2. Catheter ablation of atrial fibrillation
Catheter ablation has emerged as an alternative to
obtain stable sinus rhythm in this population. It has been demonstrated
that a significant number of AF episodes initiate in the area of the
pulmonary veins located in the left atrium.
Using one or several catheters inserted through the
femoral veins, they are inserted into the heart and brought to the left
atrium through a transseptal approach. Once in the left atrium energy
(radiofrequency, cold) is delivered in different areas (mainly around
the pulmonary veins) to create lesions that block the electrical
activity responsible for the arrhythmia.
The effectiveness of this technique is around 70% and
in about 25% a second procedure is needed to finish the ablation lines.
As any invasive procedure some major complications may occur like
cardiac tamponade (1%), thromboembolic events (0.5%) or atrio-esophageal
fistula (1/1000). In case of success the patient does not requires
continuation with AAD and the arrhythmia is cured.
The decision of which treatment to be used will have to be based on a
number of considerations: type of patient, willingness of the patient,
experience of the centre in ablative techniques, etc.
It is estimated than more than 10.000 atrial fibrillation ablation
procedures are performed annually in Europe and the number is increasing
exponentially since over the last years availability of more
sophisticated techniques and equipment has produced a marked increase in
the number of centres performing atrial fibrillation ablation. Three
dimensional mapping systems, robotic techniques, new energy sources and
new and more reliable catheters are easing the procedure and improving
efficacy and safety.
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