Spotty Management After Afib Ablation

The success of catheter ablation for atrial fibrillation (Afib) has been "satisfactory," a large European registry showed, although gaps in the management of patients leave room for concern.

At 1 year, according to the ESC-EHRA Atrial Fibrillation Ablation Long-Term registry, the procedure was associated with a success rate of 73.6% -- the proportion of patients surviving free from any atrial arrhythmia, with or without antiarrhythmic drugs, after the initial 3-month blanking period.

Importantly, however, almost half of patients were still on antiarrhythmic drugs during this time, reported Elena Arbelo, MD, PhD, of Hospital Clínic de Barcelona in Spain, and colleagues in a study published online in the European Heart Journal.

There were 14 late deaths after the procedure (four cardiac, four vascular, and four of unrelated causes) and a 10.7% rate of other complications, including two strokes, seven cardiac perforations, and 23 vascular complications.

More disturbing was the finding that only 60% of the patients subsequently received serial and multiday ECG recordings to check for recurrent Afib.

"Catheter ablation is not open heart surgery, but it is still an invasive procedure that has risks," Arbelo said in a statement. "It is disappointing that 40% of patients are not being comprehensively monitored afterwards."

Writing in the report, the authors stated: "Considering asymptomatic and late recurrences after Afib ablation, current guidelines recommend continuation of long-term anticoagulation based on the individual thromboembolic risk independent of the assumed ablation results. Despite these recommendations, at 1 year after ablation, 26.5% of patients with CHA2DS2-VASc≥2 were not anticoagulated. Conversely, a third of low-risk individuals (CHA2DS2-VASc=0) are still under oral anticoagulants.

"Sadly, the insufficient guideline-adherence in anticoagulation management, is still an issue in this study."

The registry followed 3,630 consecutive patients who underwent Afib ablation at 104 European centers. Mean age was 59 at the time of the procedure (2012-2015); 1-year follow-up was performed via clinical visits (52.8%), telephone contact (44.2%), and in-person sessions (3.0%).

The researchers called the registry the largest international prospective collection on indications, patient characteristics, techniques, and outcomes of catheter ablation of Afib to date.

One-third of patients had lone Afib; another two-thirds had paroxysmal Afib, and only 5% presented with long-lasting Afib. Patients with paroxysmal Afib were more likely to be off drugs compared with their peers with persistent Afib (P=0.0005), the team reported.

In-hospital complications occurred in 7.8% of patients -- the most common being a cardiovascular adverse event (4.1%); one patient died of an atrioesophageal fistula.

"Radiofrequency energy remains the main energy source used," the authors noted, expressing surprise at the fact that cryoballoon procedures became only incrementally more popular by going from 13% in 2012 to 16% in their study. "Other energy sources such as laser, duty-cycled radiofrequency, or high intensity-focused ultrasound, were only rarely used."

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