Contribution This systematic review found that radiofrequency ablation after a failed drug course maintained sinus rhythm more often than continuation of drug therapy alone .
The benefits of maintaining sinus rhythm with antiarrhythmic drugs appeared to be offset by the serious adverse effects of the drugs .
Context Is radiofrequency catheter ablation a better alternative than medical therapy for patients with atrial fibrillation ?
The Editors Atrial fibrillation is the most common sustained arrhythmia in clinical practice ( 1 ) .
Its prevalence increases with age , from 0.1 % in people younger than 55 years to more than 9 % by 80 years of age ( 2 ) .
The heavy burden of atrial fibrillation on morbidity , mortality , and health care re sources creates a pressing need for novel approaches to management .
In some patients , adequate pharmacologic slowing of the ventricular response rate ( a rate-control strategy ) is sufficient to control symptoms .
However , many patients remain symptomatic from the lack of organized atrial contraction and the persistent irregularity of the ventricular response in atrial fibrillation .
In such patients , the appropriate treatment is restoration of normal sinus rhythm , achieved electrically or chemically ( a rhythm-control strategy ) ( 2 ) .
Radiofrequency catheter ablation is a promising approach that offers the benefits of maintaining sinus rhythm without the adverse effects of antiarrhythmic drugs .
Catheter ablation for atrial fibrillation is based on the underst and ing that electrical activity emanating from the pulmonary veins frequently serves as a trigger for atrial fibrillation .
In the late 1990s , Hassaguerre and colleagues ( 5 ) observed that elimination of local electrograms at these foci with radiofrequency energy reduced the risk for recurrence of atrial fibrillation .
Currently , the foundation of most atrial fibrillation ablation procedures is to target and electrically isolate the pulmonary veins ( 6 ) .
This may be achieved by delivering lesions immediately outside the ostia of the pulmonary veins or along a wider area in the left atrium encircling the veins .
Additional lesion sets have been used to ablate nonpulmonary vein triggers of atrial fibrillation and to target atrial areas thought to be responsible for maintaining atrial fibrillation ( 6 ) .
These linear lesions may be created in the posterior left atrium , the roof of the left atrium , the interatrial septum , and the isthmus formed between the mitral annulus and the pulmonary vein or left atrial appendage .
At present , the Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation , put forth by the Heart Rhythm Society and endorsed by several professional organizations , states that the foundation of most atrial fibrillation ablation procedures is to target the pulmonary veins , pulmonary vein antra , or both ( 6 ) .
The panel advised us that 8-mmtip and irrigated-tip catheters are now the catheters of choice for radiofrequency ablation of atrial fibrillation in the United States .
The conventional 4-mmtip catheter is rapidly being phased out of use for this indication .
The following 3 key questions were formulated : 1 .
What is the effect of radiofrequency catheter ablation on short-term ( 6 to 12 months ) and long-term ( > 12 months ) rhythm control ; rates of congestive heart failure ; changes in the size of the left atrium and ventricle ; rates of stroke ; quality of life ; avoiding anticoagulation ; and readmissions for paroxysmal , persistent , and long-st and ing persistent ( chronic ) atrial fibrillation ?
2 .
How does the effect of radiofrequency ablation  on rhythm control differ among the various techniques used ?
3 .
What are the short- and long-term complications and harms associated with radiofrequency ablation ?
Mortality, morbidity, and quality of life after circumferential pulmonary vein ablation for atrial fibrillation: outcomes from a controlled nonrandomized long-term study.
OBJECTIVES This study was design ed to investigate the potential of circumferential pulmonary vein ( PV ) ablation for atrial fibrillation ( AF ) to maintain sinus rhythm ( SR ) over time , thus reducing mortality and morbidity while enhancing quality of life ( QoL ) . BACKGROUND Circumferential PV ablation is safe and effective , but the long-term outcomes and its impact on QoL have not been assessed or compared with those for medical therapy . METHODS We examined the clinical course of 1,171 consecutive patients with symptomatic AF who were referred to us between January 1998 and March 2001 . The 589 ablated patients were compared with the 582 who received antiarrhythmic medications for SR control . The QoL of 109 ablated and 102 medically treated patients was measured with the SF-36 survey . RESULTS Median follow-up was 900 days ( range 161 to 1,508 days ) . Kaplan-Meier analysis showed observed survival for ablated patients was longer than among patients treated medically ( p < 0.001 ) , and not different from that expected for healthy persons of the same gender and calendar year of birth ( p = 0.55 ) . Cox proportional-hazards model revealed in the ablation group hazard ratios of 0.46 ( 95 % confidence interval [ CI ] , 0.31 to 0.68 ; p < 0.001 ) for all-cause mortality , of 0.45 ( 95 % CI , 0.31 to 0.64 ; p < 0.001 ) for morbidities mainly due to heart failure and ischemic cerebrovascular events , and of 0.30 ( 95 % CI , 0.24 to 0.37 ; p < 0.001 ) for AF recurrence . Ablated patients ' QoL , different from patients treated medically , reached normative levels at six months and remained unchanged at one year . CONCLUSIONS Pulmonary vein ablation improves mortality , morbidity , and QoL as compared with medical therapy . Our findings pave the way for r and omized trials to prospect a wider application of ablation therapy for AF
Contribution This systematic review found that radiofrequency ablation after a failed drug course maintained sinus rhythm more often than continuation of drug therapy alone .
The benefits of maintaining sinus rhythm with antiarrhythmic drugs appeared to be offset by the serious adverse effects of the drugs .
Context Is radiofrequency catheter ablation a better alternative than medical therapy for patients with atrial fibrillation ?
The Editors Atrial fibrillation is the most common sustained arrhythmia in clinical practice ( 1 ) .
Its prevalence increases with age , from 0.1 % in people younger than 55 years to more than 9 % by 80 years of age ( 2 ) .
The heavy burden of atrial fibrillation on morbidity , mortality , and health care re sources creates a pressing need for novel approaches to management .
In some patients , adequate pharmacologic slowing of the ventricular response rate ( a rate-control strategy ) is sufficient to control symptoms .
However , many patients remain symptomatic from the lack of organized atrial contraction and the persistent irregularity of the ventricular response in atrial fibrillation .
In such patients , the appropriate treatment is restoration of normal sinus rhythm , achieved electrically or chemically ( a rhythm-control strategy ) ( 2 ) .
Radiofrequency catheter ablation is a promising approach that offers the benefits of maintaining sinus rhythm without the adverse effects of antiarrhythmic drugs .
Catheter ablation for atrial fibrillation is based on the underst and ing that electrical activity emanating from the pulmonary veins frequently serves as a trigger for atrial fibrillation .
In the late 1990s , Hassaguerre and colleagues ( 5 ) observed that elimination of local electrograms at these foci with radiofrequency energy reduced the risk for recurrence of atrial fibrillation .
Currently , the foundation of most atrial fibrillation ablation procedures is to target and electrically isolate the pulmonary veins ( 6 ) .
This may be achieved by delivering lesions immediately outside the ostia of the pulmonary veins or along a wider area in the left atrium encircling the veins .
Additional lesion sets have been used to ablate nonpulmonary vein triggers of atrial fibrillation and to target atrial areas thought to be responsible for maintaining atrial fibrillation ( 6 ) .
These linear lesions may be created in the posterior left atrium , the roof of the left atrium , the interatrial septum , and the isthmus formed between the mitral annulus and the pulmonary vein or left atrial appendage .
At present , the Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation , put forth by the Heart Rhythm Society and endorsed by several professional organizations , states that the foundation of most atrial fibrillation ablation procedures is to target the pulmonary veins , pulmonary vein antra , or both ( 6 ) .
The panel advised us that 8-mmtip and irrigated-tip catheters are now the catheters of choice for radiofrequency ablation of atrial fibrillation in the United States .
The conventional 4-mmtip catheter is rapidly being phased out of use for this indication .
The following 3 key questions were formulated : 1 .
What is the effect of radiofrequency catheter ablation on short-term ( 6 to 12 months ) and long-term ( > 12 months ) rhythm control ; rates of congestive heart failure ; changes in the size of the left atrium and ventricle ; rates of stroke ; quality of life ; avoiding anticoagulation ; and readmissions for paroxysmal , persistent , and long-st and ing persistent ( chronic ) atrial fibrillation ?
2 .
How does the effect of radiofrequency ablation  on rhythm control differ among the various techniques used ?
3 .
What are the short- and long-term complications and harms associated with radiofrequency ablation ?