CABANA: AF ablation ties drug management, with an asterisk for crossovers

The data from CABANA suggest that at the least, catheter ablation is the equivalent of drug therapy, and I think in many cases, it is probably superior. Patients with atrial fibrillation should be allowed to undergo ablation as their first treatment, performed by operators who know what they’re doing. These are excellent results, but they do not apply to every patient with atrial fibrillation; they apply to patients like those enrolled in the trial.

Some people will look at the results from the intention-to-treat analysis of the primary endpoint and say that this is a neutral result. The patients who I treat often ask me “if I get this treatment, what will likely happen to me.” They are not interested in what happened to patients in a trial who never received the treatment they were supposed to get. I recommend that people interested in CABANA, look at the full data set and do not limit themselves to a knee-jerk reaction to the intention-to-treat analysis.

The results also speak very loudly about the importance of sinus rhythm in patients with heart failure. The results in the subgroup of patients with heart failure appear to support the findings from CASTLE-AF (N Engl J Med. 2018 Feb 1;378[5]:417-27).

Eric N. Prystowsky, MD , is a cardiac electrophysiologist with the St. Vincent Medical Group in Indianapolis. He has been a consultant to CardioNet and Medtronic, has an equity interest in Stereotaxis, and receives fellowship support from Medtronic and St. Jude. He made these comments as designated discussant for CABANA.