In a remarkably frank article, US cardiologist John Mandrola has written in a thought-provoking style on whether AF Ablation is really the best way to address atrial fibrillation.
The article, entitled “AF Ablation?: What are we doing?” can be found in full at theheart.org, here. In it the author quotes a cardiologist colleague, stating; “Atrial fibrillation isn’t an immediately life-threatening disease; don’t make it one.”
Dr Mandrola asks searching questions about the intervention:
- Would you have AF ablation? Would you wonder about the long-term effects?
- What about the rightness of poking a needle across a beating atrial septum? What of the idea of making 50 or more burns in the delicate left atrium? And those lines?
- Are we curing AF? Are we changing the natural history of the disease?
- Is AF ablation akin to placing stents for chronic coronary disease: just a big procedure to reduce symptoms, without improving real outcomes? Similarly, as stents do with their need for antiplatelet drugs, does AF ablation create yet another disease: a poorly contractile left atrium for one, asymptomatic brain lesions, another.
The AF Quandary
It’s perhaps unsurprising for a cardiologist to state that reeing patients from the shackles of AF (or AF drugs) feels so good, coupled with the fact that according to the author few AF patients can stand (or are best served with) no treatment. However he goes on to accept the downsides:
“..sometimes our efforts make matters worse. Blood-thinners worsen bleeding, medicines cause side effects or worse, proarrhythmia, and ablation exposes patients to serious risk.”
AF catheter ablation: Improving survival or quality of life or both?
AF is associated with higher incidence of stroke and early death and in many patients imposes limitations on their lifestyle. So the author asks whether simply reducing symptoms is enough, because he claims we cannot yet confidently claim ablation reduces the progression of the disease even when “symptoms” have been reduced. In other words, symptom “reduction” doesn’t necessarily correlate with a change in the natural history of the disease which may remain underlying but masked by improvement as expressed by patients.
“Numerous studies show that patients treated with AF ablation, when compared with AF patients on meds, have fewer AF episodes and report higher quality-of-life scores. Yet these studies shed little light on how (or if) AF ablation changes the natural history of the disease.”
Risks of AF Ablation
Defining success: Patients will claim to be “better” despite having symptoms, which may indicate that their risk profile for stroke has not been reduced (as even occasional/mild AF is known to carry the stroke risk).
The downsides of the burns; What are the long-term effects of ablation? The ones we know about small brain lesions, decreased LA function) as well as the ones we might not.
Retrospective data suggests AF ablation may reduce stroke rate
The Australian/British collaborative AF registry of 1273 patients who had AF ablation, gave cause for optimism.
“Compared with a group of medically treated patients and a hypothetical group of similar patients without AF, those treated with AF ablation had far fewer strokes and better survival. Freedom from AF after ablation lowered the stroke rate by 70%. Females, who typically fare less well with AF, did especially well with ablation. Using historical controls and registry data has important limitations, but these encouraging results align well with other recent look-back trials of AF ablation.”
The author believes that “although the picture is unfinished, a mosaic begins to take shape. As experience and technology make AF ablation safer and perhaps more effective, it becomes plausible to believe in the possibility that our hard-won ablation skills may change the course of the disease.”
We applaud anyone who has the ability, courage, confidence, self-doubt, honesty, call it what you will, to put under the microscope something he and thousands of other cardiologists do on a daily basis. It’s reassuring to see that the author concludes that despite a lack of concrete evidence (wasn’t it ever thus?) it seems likely that AF Ablation is the best that can be done for the right patient, with the caveat that while it appears to be a safe and effective way of relieving symptoms of AF it has a less clear impact on the natural history of the disease.
Our analysis of the piece however is that it’s refreshing to read about a clinician who is prepared to forensically and publicly dissect his own day job. It’s a fine line between having the confidence to sit across the table from patients whose life is truly in your hands, yet enough self-criticism and doubt to question everything you do.