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 ?
Segmental pulmonary vein ablation: success rates with and without exclusion of areas adjacent to the esophagus.
BACKGROUND Catheter ablation has become the first line of therapy in patients with symptomatic recurrent , drug-refractory atrial fibrillation ( AF ) . The occurrence of an atrioesophageal fistula is a rare but serious complication after AF-ablation procedures . This risk is even present during segmental pulmonary vein ( PV ) ablation procedures because the esophagus does frequently have a very close anatomical relationship to the right or left PV ostia . The aim of the present study was to analyze whether the exclusion of areas adjacent to the esophagus does have a significant effect on the success rates after segmental pulmonary vein ablation procedures . METHODS Forty-three consecutive patients with symptomatic paroxysmal AF were enrolled in this study . In all patients , a segmental PV ablation procedure was performed . The procedures were facilitated by a 3D real-time visualization of the circumferential mapping catheter placed in the pulmonary veins using the NavX system ( St. Jude Medical , St. Paul , MN , USA ; open irrigated tip ablation catheter ; 43 degrees C ; 30 W ) . In 21 patients , a complete ostial PV isolation was attempted regardless of the anatomical relationship between the ablation sites and the esophagus ( group A ) . In the remaining 22 patients , the esophagus was marked by a stomach tube and areas adjacent to the esophagus were excluded from the ablation procedure ( group B ) . After discharge , patients were scheduled for repeated visits at the arrhythmia clinic at 1 , 3 , and 6 months after the ablation procedure . RESULTS The segmental pulmonary vein ablation procedure could be performed as planned in all patients . In group A , all pulmonary veins could be isolated successfully in 14 out of 21 patients ( 67 % ) . A mean number of 3.7 pulmonary veins ( SD + /- 0.5 PVs ) were isolated per patient . The main reasons for an incomplete PV isolation were : small diameter of the PVs , side branches close to the ostium , or poorly accessible PV ostia . In group B , all PVs could be isolated successfully in only 12 out of 22 patients ( 55 % ; P = 0.54 ) . A mean number of 3.2 PVs ( SD + /- 0.9 PVs ) were isolated per patient ( P = 0.05 ) . This was mostly due to a close anatomical relationship to the esophagus . The ablation strategy had to be modified in 16/22 patients in group B because of a close anatomical relationship between the left ( n = 10 ) or right ( n = 6 ) PV ostia and the esophagus . After 3 months , the percentage of patients free from an AF recurrence was not significantly different between the two groups ( 90 % vs 95 % ; P = 0.61 ) . After 6 months , there was no significant difference between the success rates either ( 81 % vs 82 % ; P = 1.0 ) . There were no major complications in both groups . CONCLUSIONS The exclusion of areas adjacent to the esophagus results in a moderately higher percentage of incompletely isolated PVs . However , it does not have a significant effect on the AF recurrence rate during short-term and mid-term follow-up
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 ?