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FOCUS ISSUE: ATRIAL FIBRILLATION: CLINICAL RESEARCH: ABLATION THERAPY OF ATRIAL FIBRILLATION

Clinical Outcomes of Catheter Substrate Ablation for High-Risk Patients With Atrial Fibrillation

Pacific Rim Electrophysiology Research Institution, Inglewood, California.

Manuscript received August 22, 2007; revised manuscript received October 10, 2007, accepted October 29, 2007.

^_* Reprint requests and correspondence: Dr. Koonlawee Nademanee, Pacific Rim Electrophysiology Research Institution, 575 E. Hardy Street, #201, Inglewood, California 90301. (Email: wee{at}pacificrimep.com).

Objectives: The purpose of this study was to determine the long-term clinical outcomes of catheter ablation of atrial fibrillation (AF) substrate for high-risk patients with AF.

Background: The benefits of catheter ablation for high-risk AF patients with respect to mortality and stroke reductions remain unclear.

Methods: We performed AF substrate ablation guided by complex fractionated atrial electrogram (CFAE) mapping in 674 high-risk AF patients. The clinical end points were sinus rhythm (SR), death, stroke, or bleeding. Of these 674 patients, 635 were available for follow-up and made up the study cohort. The patients were relatively old (mean age 67 ± 12 years) and 129 had an ejection fraction (EF) <40%.

Results: After the mean follow-up period of 836 ± 605 days, 517 were in SR (81.4%). There were 15 deaths among the patients who stayed in SR compared with 14 deaths among those who remained in AF (5-year survival rate, 92% vs. 64%, respectively; p < 0.0001). SR was the most important independent favorable parameter for survival (hazard ratio 0.14, 95% confidence interval 0.06 to 0.36, p < 0.0001), whereas old age was unfavorable. Warfarin therapy was discontinued in 434 of the 517 patients in SR post-ablation (84%) whose annual stroke rate was only 0.4% compared with 2% in those with continuing warfarin treatment (p = 0.004).

Conclusions: CFAE-targeted ablation of AF is effective in maintaining SR in selected high-risk AF patients and might allow patients to stop warfarin therapy. SR after AF ablation is a marker of relatively low mortality and stroke risk. Our findings support conducting further randomized studies to determine whether AF ablation is associated with mortality and/or stroke reduction.

Abbreviations and Acronyms   AF = atrial fibrillation   CFAE = complex fractionated atrial electrogram   CI = confidence interval   CVA = cerebrovascular accident   EF = ejection fraction   HR = hazard ratio   INR = international normalized ratio   RF = radiofrequency   SR = sinus rhythm   TIA = transient ischemic attack

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