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  •    Non-Paroxysmal AF predicts recurrence after AF ablation, a systematic review confirms
    Sunthosh Parvathaneni MD, University Hospitals Case Medical Center, Case Western Reserve University, Harrington-McLaughlin Heart & Vascular Institute, Cleveland, Ohio.

    Atrial Fibrillation (AF) is a highly prevalent disease, affecting approximately 2 million people in the United States, which impacts morbidity, including quality of life and catastrophic cerebral events.  The incidence of AF increases with age, 8-9% in patients > 80 years, and accounts for 6-24% of ischemic strokes. For these reasons, AF radiofrequency ablation (RFA) has gained considerable favorability, particularly, in those patients refractory to antiarrhythmic therapy.  Determinants of success from RFA therapy depend on patient factors. The population that suffers from AF is heterogeneous in nature containing a wide variety of ailments from hypertension to heart failure.  Rates of success and maintaining sinus rhythm varies; ranging from 30-85%, with larger success with patients suffering from paroxysmal atrial fibrillation (PAF) and those with less co-morbidity.  However, to date, data on predictors of success with AF RFA is sparse.

    Balk et al. 2010 did a large systematic review involving studies with patients who underwent AF RFA, incorporating research, both prospective and retrospective longitudinal research, from 2000 through 2008, with total citations of 2169, which was further narrowed down to 45. The authors focused on pre-RFA characteristics that were likely to predict AF recurrence, such as: AF type (paroxysmal, persistent, permanent, and non-paroxysmal), AF duration from onset of symptoms, left ventricular ejection fraction (EF), left atrial diameter (LAD), gender, age, presence of structural disease, and hypertension. Not included in their search were procedure related characteristics or within procedure findings as well as studies limited to congenital heart disease, hypertrophic cardiomyopathy, or Wolf-Parkinson-White Syndrome.  From these resources, the authors extracted multivariable analyses and univariable data on predictors of and AF recurrence.  The literature was highly heterogeneous in terms of study design, patient population, RFA technique (pulmonary vein isolation versus wide area circumferential ablation), definition of AF recurrence, regression analysis methods, and among other issues.  The range of follow up after ablation was 6 to 41 months with a median of 12 months.

    Among 25 studies that underwent multivariate analysis about 66-90% of the literature found that AF type, EF, LAD, structural heart disease, hypertension, and AF symptom duration did not predict AF recurrence, particularly in those patients with an EF > 40% and LAD less than 5.5 cm.  In addition, the authors found that gender and age (between 40 and 70 years) were not significant predictors for AF recurrence.  Meta-analyses of 31 investigations found that the research was widely heterogeneous but, more importantly, patients with non-paroxysmal AF predicted AF recurrence compared to those with paroxysmal AF with similar results when comparing persistent/permanent and PAF (RR 1.59; 95% CI 1.38-1.82; p < 0.001).

    The results of the systematic review revealed that no individual or group of pre-procedural characteristics consistently predicted AF recurrence after RFA. The study was limited due to the heterogeneous nature of the reviewed research.  However, patients with non-paroxysmal AF were 60% more likely to experience an AF recurrence after RFA than those with PAF, in patients aged 40-70 years, without severe heart disease, normal EF, and normal LAD.

    References:

    1. Balk EM, Garlitski AC, Alsheikh-Ali AA, Terasawa T, Chung M; IP S: Predictors of atrial fibrillation recurrence after radiofrequency catheter ablation: A systematic review. J Cardiovasc Electrophysiol 2010: 1-9.

    2. Cheema A, Vasamreddy CR, Dalal D, Marine JE, Dong J, Henrikson CA, Spragg D, Cheng A, Nazarian S, Sinha S, Halperin H, Berger R; Calkins H: Long-term single procedure efficacy of catheter ablation of atrial fibrillation. J Interv Card Electrophysiol 2006; 15: 145-155.

    3. Pappone C, Rosanio S, Oreto G, Tocchi M, Gugliotta F, Vicedomini G, Salvati A, Dicandia C, Mazzone P, Santinelli V, Gulletta S, Chierchia S: Circumferential radiofrequency ablation of pulmonary vein ostia: A new anatomic approach for curing atrial fibrillation. Circulation 2000; 102: 2619-2628.

    4. Ip S, Terasawa T, Balk EM, Chung M, Alsheikh-Ali AA, Garlitski AC, Lau J: Comparitive effectiveness of radiofrequency catheter ablation for atrial fibrillation. Comparative Effectiveness Review No. 15 (Prepared by Tufts Medical Center Evidence-based Practice Center under Contract No. 290-02-022.) Rockville, MD: Agency for Healthcare Research and Quality, 2009. Available at: www.effectivehealthcare.ahrq.gov/reports/final.cfm.

    5. Terasawa T, Balk EM, Chung M, Garlitski AC, Alsheikh-Ali AA, Lau J, IP S: Systematic review: Comparitive effectiveness of radiofrequency catheter ablation for atrial fibrillation. Ann Intern Med 2009; 151: 191-202.


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