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Catheter Ablation Emerging Treatment for Atrial Fibrillation

New York (Apr 27, 2010)

illustration of a human heart

Pharmacologic therapy with anti-arrhythmia drugs is the first line of treatment for patients with symptomatic atrial fibrillation. Today cardiac electrophysiologists are increasingly using catheter ablation to treat patients with atrial fibrillation that is refractory to anti-arrhythmic medication. The cardiac electrophysiologists at NewYork-Presbyterian Hospital are very experienced and highly skilled in the use of catheter ablation to treat patients with atrial fibrillation, with some of the best outcomes in the nation.

"There are 2.4 million people in the United States with atrial fibrillation, tens of thousands of whom receive catheter ablation each year," said Bruce B. Lerman, M.D. "Yet many more may be eligible for this effective procedure which successfully restores heart rhythm and prohibits the need for lifetime medication in the majority of patients."

Current Guidelines

Current guidelines issued by the American Heart Association, American College of Cardiology, and European Society of Cardiology recommend one or more anti-arrhythmic drugs as initial therapy for patients with atrial fibrillation, with catheter ablation reserved for those patients whose atrial fibrillation is refractory to pharmacologic therapy. Digoxin, beta blockers (atenolol, metoprolol, or propranolol), or calcium antagonists (verapamil or diltiazem) are often used to control ventricular rate. Drugs that can suppress atrial fibrillation include flecainide, propafenone, sotalol, dofetilide, dronedarone, and amiodarone.

Bruce B. Lerman, M.D.
Bruce Lerman, M.D.

But in some patients, such drugs are not sufficient, and catheter ablation may be a therapeutic option. In February 2009, the U.S. Food and Drug Administration approved the first ablation catheters designed specifically for the treatment of paroxysmal atrial fibrillation: the NAVISTAR® THERMOCOOL® and EZ Steer THERMOCOOL® Nav Irrigated Deflectable Diagnostic/Ablation Catheters.

About Ablation

Using an endovascular approach, radiofrequency catheter ablation uses intense energy to destroy sleeves of atrial tissue surrounding the pulmonary veins, the source of the arrhythmia. The "firewall" between the pulmonary veins and left atrium created via ablation results in a restoration of normal heart rhythm.

Hasan Garan, M.D.
Hasan Garan, M.D.

In some patients, this firewall may become compromised, and electrical connections are re-established between the pulmonary vein(s) and left atrium, triggering a recurrence of the arrhythmia. In these cases, a second ablation procedure may be indicated, usually several months after the initial ablation.

Catheter ablation is most effective for paroxysmal atrial fibrillation and is usually reserved for patients age 80 and younger. Patients over 80 are at more risk for complications – such as cardiac tamponade, stroke, atrio-esophageal fistula, and phrenic nerve paralysis – and as a result, the technique is only indicated in these patients in the most severe cases. Catheter ablation is also less effective in atrial fibrillation patients with underlying structural heart disease, such as hypertrophic cardiomyopathy.

In a subset of patients, atrial fibrillation may impair ejection fraction, prompting some physicians to diagnose idiopathic dilated cardiomyopathy. But this reduction in heart function may be due to tachycardia-induced cardiomyopathy related to atrial fibrillation that can be successfully treated with catheter ablation.

Catheter ablation may enable patients to forego Coumadin therapy and enjoy an improved quality of life as they achieve a normal sinus rhythm.

CABANA Clinical Trial

A multicenter international study called the Catheter Ablation versus Anti-arrhythmic Drug Therapy for Atrial Fibrillation (or CABANA) Trial will be the largest study to date comparing catheter ablation with pharmacologic treatment for patients with atrial fibrillation. Funded by the National Heart, Lung, and Blood Institute, the phase IV study is enrolling 3,000 patients who will be randomized to have a catheter ablation procedure or receive anti-arrhythmic drug therapy.

Results of the study will help physicians determine which treatment approach is best overall and, in certain circumstances, which therapy may be the preferred choice for an individual patient. NewYork-Presbyterian Hospital/Columbia University Medical Center is one of 140 leading centers from around the world to participate in the CABANA Trial.

Several prior studies have demonstrated that catheter ablation is superior to drug therapy for suppression of symptomatic paroxysmal atrial fibrillation, but they have focused on "soft" endpoints, such as relief of symptoms and quality of life, and included small numbers of patients. The CABANA study is the first to examine the impact of these therapies on objective "hard" endpoints, including total mortality (the primary endpoint) and secondary endpoints such as the incidence of stroke, intracranial bleeding, and cardiac arrest. Other secondary endpoints include the cost of care and quality of life.

Patients who are randomized to the ablation group will undergo the procedure using open irrigation deflectable ablation catheters. Patients receiving standard pharmacologic anti-arrhythmic treatment will receive medication chosen at the discretion of the treating physician. Participants will be enrolled over three years and followed for up to six years. Eligible patients for the CABANA Trial must be age 18 or over. Patients must have documented atrial fibrillation episodes lasting one hour or more, with two or more episodes occurring over four months with electrocardiographic documentation of one episode, or at least one episode lasting more than one week.

Said Hasan Garan, M.D., "If the CABANA study shows that ablation is superior to pharmacologic therapy for atrial fibrillation, it's possible that many eligible patients will be offered a choice of catheter ablation or drug therapy right up front."

For More Information About CABANA Clinical Trial

For more information about the CABANA Trial, visit clinicaltrials.gov and search study number NCT00911508. To enroll a patient in this trial at NewYork-Presbyterian/Columbia, call the Cardiac Electrophysiology Service at 212-305-1533.

Contributing faculty for this article:

Bruce B. Lerman, M.D. is Chief of the Division of Cardiology; Director of the Cardiac Electrophysiology Laboratory; and an Attending Physician at NewYork-Presbyterian Hospital/Weill Cornell Medical Center. He is also the Hilda Altschul Master Professor of Medicine at Weill Cornell Medical College.

Hasan Garan, M.D. is Director of the Cardiac Electrophysiology Service and an Attending Physician at NewYork-Presbyterian Hospital/Columbia University Medical Center. He is also a Professor of Medicine at Columbia University College of Physicians and Surgeons.

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