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  •    Is AF Ablation a Safe First Line Therapy in Younger Patients?
    Siva Soma MD, Allegheny General Hospital, Pittsburgh, PA.

    Current guidelines (ACC/AHA/ESC 2006 guidelines) for treatment of AF recommend that ablation is a second line therapy in all categories (1). It is a first line therapy only in rare clinical situations. The article by Leong-sit et al. (2) argues it is time we consider it a first line therapy in younger patients (age<45). In a retrospective study of 1548 patients undergoing 2038 ablations, at University of Pennsylvania between 2000 and 2008, younger patients had the comparable efficacy rates with much lower complication rates.


    The results were analyzed in 4 age groups: <45 years, 45-54 years, 55-64 years and ≥65 years. Baseline characteristics showed that there was no significant difference in the proportion of patients with paroxysmal versus persistent AF and LVEF. However, group 1 (<45) had a smaller LA size, lower CHADS score and shorter procedural time compared to the other groups. The follow up period for the groups ranged between 28-32 months.


    AF control was defined as no episodes of AF (off or on anti arrhythmic drugs) and rare AF.  It was similar in all groups (p=0.06). AF control in Group 1, 2, 3 and 4 were 87%, 88%, 88% and 82% respectively. The proportion of patients who were free from AF off of AADs was higher in the younger patients. Over the follow-up period, 76% of patients in group 1 were free from AF off of AAD  compared with 68% in group 2, 65% in group 3, and 53% in group 4 (P<0.001). This is an important factor in younger patients who are reluctant to use long term AADs given their significant adverse effect profile.


    In patients younger than 45 there were no major complications and only 0.6% had minor complications. The major complication rates in Group 2, 3 and 4 were 1.7%, 2 % and 2.6% respectively (p < 0.01). The  non-major complication rates were  0.6%(n=2)  in group 1; 2.3% (13)  in group 2; 2.9% (22) in  group 3; and  4.5% (15) in group 4. The authors state that the smaller atria, shorter procedure times, predictable vascular/cardiac anatomy and fewer co morbidities might explain the significantly smaller incidence of major and minor complications. So, younger and healthier patients had more to benefit, at a lesser risk, from AF ablation when compared to older populations.


    One major drawback of the study is that it is an observational study. It does lay down the ground work for more randomized control trials comparing AF ablation versus AADs as first line therapy.   Currently there are two ongoing studies including RAAFT Study (First Line Radiofrequency Ablation Versus Antiarrhythmic Drugs for Atrial Fibrillation Treatment -Clinical identifier: NCT00392054) and MANTRA PAF (Radiofrequency Ablation (RFA) Versus Antiarrhythmic Drug Treatment in Paroxysmal Atrial Fibrillation Identifier: NCT00133211) which are multi center randomized trials recruiting patients.




    1. Fuster V, Ryden LE and Cannom DS et al. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation). J Am Coll Cardiol. 2006; 48:854 –906.


    2. Leong-Sit P, Zado E, Callans DJ, Garcia F, Lin D, Dixit S, Bala R, Riley MP, Hutchinson MD, Cooper J, Gerstenfeld EP, Marchlinski FE. Efficacy and risk of atrial fibrillation ablation before 45 years of age. Circ Arrhythm Electrophysiol. 2010 Oct 1; 3(5):452-7.



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