We read with interest the commentary about our article from Leung and
colleagues.1 We agree with their conclusion that
ablation for atrial fibrillation (AF) should be viewed by all healthcare
providers that manage patients with AF as a more effective long-term
strategy than antiarrhythmic drug therapy. We also believe that based
upon the CABANA trial results, that we have adequately powered
randomized prospective trial data to support ablation as a first line
rhythm control therapy compared to usual care for AF.2Trial data also support the use of ablation and a more cost-effective
treatment approach for AF.3 However, ablation must be
performed in specialized centers which limits availability and broad use
and its benefits are optimized when treatment is founded on risk factor
modification, medication compliance, and long-term adherence to a
healthier life.
The authors highlight that in patients with structural heart disease
that the AF subtype is of often more advanced and as such the outcomes
with ablation are less favorable. Although not reported in our
manuscript of interest, we have previously reported the AF subtypes in
patients with heart failure (ejection fraction <35%) that
received an ablation for AF in the Intermountain Healthcare system (AF
was paroxysmal in 30%, persistent in 30%, and longstanding persistent
in 40%).4 In comparison, the AF subtypes of the
general ablation population were paroxysmal in 55%, persistent in 27%,
and longstanding persistent in 18%.5 The report of
the subtypes in our prior studies was not precise in the studies as they
are derived from a large database, however the trends support the
concept that the outcomes of ablation in patients with heart failure
will likely improve with earlier referral and treatment when relatively
more patients are characterized as paroxysmal and progressive atrial
myopathy has not developed.
Next, the authors comment on the role of ablation approach and how this
can impact observed outcomes. Unfortunately, we did not have consistent
data on the ablation approach across multiple hospitals performed by
many electrophysiologists in the database. Throughout the healthcare
system, pulmonary vein isolation was a goal of therapy, and most
ablations were performed with radiofrequency energy. Randomized control
data support pulmonary vein isolation alone as a strategy in patients
with favorable substrate and arrhythmia subtypes including for
persistent AF.6 Additional linear ablation or
targeting of arrhythmogenic substrate is often performed with severe
atrial myopathies and more advanced AF subtypes which can create
iatrogenic arrhythmias, and even without these arrhythmias, recurrences
rates are still higher compared to those observed in patients with
paroxysmal atrial fibrillation.
We agree with the authors that evidence is mounting not only for first
line ablation but also earlier rhythm control in general. The EAST-AF
Net trial supports early rhythm control (both with ablation and
antiarrhythmic medications) to impact the natural history of AF lowering
risk of cardiovascular death, stroke, or hospitalization with worsening
of heart failure, acute coronary syndrome, and days spent in the
hospital in both symptomatic and asymptomatic patients with AF when
performed in the context of comprehensive management of coexistent
diseases and comorbidities.7 However, extrapolation of
published data to sicker and different populations will require our
community of electrophysiologists to perform the needed studies to
support it use, in a way that is convincing to the physicians that refer
patients to us, and advance the science of AF management beyond industry
interests alone that often define many of the current prospective
ablation trials.