A new study shows that performing catheter ablation on patients who have atrial fibrillation (an irregular heart beat) along with heart failure yields better outcomes than treating the irregular heartbeat with a medication.
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There are only two or three medications that can be used for atrial fibrillation. The study looked at the drug amiodarone. It was presented at the annual meeting of the American College of Cardiology earlier this year.
Walid Saliba, MD, a Cleveland Clinic electrophysiologist, says this study was different from previous studies comparing amiodarone to ablation because it only looked at patients who also have heart failure.
“Keeping this group of patients out of atrial fibrillation is definitely an unmet need today,” he says. “They have higher hospitalization rates and higher recurrence rates of atrial fibrillation because it tends to co-exist with heart failure.”
He says the study, which was performed in the Texas Cardiac Arrhythmia Institute at St. David’s Medical Center and Albert Einstein College of Medicine and Montefiore Medical Center, New York City, included 203 patients. Half underwent catheter ablation and half received amiodarone.
Two years later, researchers found that 70 percent of the patients who the ablation had no atrial fibrillation, compared with 34 percent of patients who were given the medication.
Dr. Saliba says that while ablation procedures have some risks, this study helps show that many of the risks are worth it. He notes that the medication also has risks, and patients taking it for a long time need to have regular exams to check their thyroid, liver, lungs, eyes, skin and central nervous system for problems.
“Amiodarone is a strong medication and we do not like to give it to young patients since they would face year of possible side effects,” he says. “We have thought it was best used for a short time with a specific goal, such as giving it until the patient can have an ablation. This study shows us that this is the correct approach for most patients.”
However, he notes that ablation does not “cure” atrial fibrillation, especially in heart failure patients. It tends to maximize the chance of staying in normal rhythm. Those who still have symptoms, such as shortness of breath, may need to try the medication as well.
What is ablation?
The catheter ablation procedure for atrial fibrillation is called pulmonary vein antrum isolation (PVAI). During the procedure the electrophysiologist inserts a thin, flexible tube through arteries in both sides of the groin and directs them through the body to the heart. A special machine delivers energy through the catheter to the areas of the heart around the pulmonary veins, preventing the abnormal signals that cause atrial fibrillation from reaching the rest of the atrium.
Patients usually are asleep or in a “conscious sedation” so they do not feel pain. The procedure lasts about 4 hours. Patients usually stay one night in the hospital for monitoring but otherwise can resume normal activities quickly.
They may have small amounts of chest discomfort for a few days but this is not usually a big problem. There is a small risk of problems such as stroke or damage to the heart, but these are rare, Dr. Saliba says.
A step in the right direction
He notes that this is a small study, and more research is needed on the best ways to treat atrial fibrillation in heart failure patients, but he calls it a step in the right direction.
“The study found that overall mortality was 8 percent in the ablation group, but 18 percent in the amiodarone group,” he says. “This is a positive finding that helps reaffirm the results from other studies that show ablation offers the greatest chance of success for heart failure patients.”
This is significant because it means keeping patients in normal rhythm without medication. “We are potentially changing the natural history of the disease,” he concludes.