DENVER — Announcement of the first-ever formal international consensus statement on catheter and surgical ablation of atrial fibrillation couldn't have come at a better time to help restore luster to the field's tarnished credibility, leading electrophysiologists agreed in a panel discussion held to celebrate the document's release at the annual meeting of the Heart Rhythm Society.
“This document is important because it comes at a time when we're very close to losing all of our credibility, whether you're talking about referring physicians or government agencies or insurance providers. I think a lot of distrust has been building,” said Dr. David J. Callans, professor of medicine and director of the electrophysiology laboratory at the Hospital of the University of Pennsylvania, Philadelphia.
The source of the plummeting credibility over the past 2–3 years, as atrial fibrillation (AF) ablation has really taken off in popularity, is twofold: implausibly wide variation in published efficacy rates, and growing recognition that there has been widespread underreporting of complications, he added.
Dr. Kenneth A. Ellenbogen said that published treatment success rates at high-volume centers range from 11% to 100%.
“It boggles the mind. When people see that they ask, 'What's going on?'” said Dr. Ellenbogen, professor of medicine and vice chairman of cardiology at the Medical College of Virginia, Richmond.
Dr. Peter R. Kowey said he, too, gets asked that discomfiting question a lot. “There is a good deal of unhappiness among many people who have referred us patients, because of our inability to really get our hands around this issue,” added Dr. Kowey, president of the Heart Center at Main Line Health System, Philadelphia, and professor of medicine at Jefferson Medical College, Philadelphia.
The consensus statement was developed by the Heart Rhythm Society, the European Heart Rhythm Association, and the European Cardiac Arrhythmia Society in collaboration with the American College of Cardiology, American Heart Association, and Society of Thoracic Surgeons. It lays out recommendations for the indications for ablation, techniques, patient follow-up, and training and competency of operators, as well as the expected range of results.
“These guidelines are a major step toward helping physicians provide better, safer, and more consistent care,” declared Dr. Hugh Calkins, chair of the task force that developed the expert consensus statement and professor of medicine and director of the arrhythmia service and electrophysiology laboratory at the Johns Hopkins Hospital, Baltimore.
The 46-page “Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: Recommendations for Personnel, Policy, Procedures, and Follow-up” addresses technical aspects of the procedure in greater detail than did last year's ACC/AHA/European Society of Cardiology (ESC) revised practice guidelines on the management of atrial fibrillation (J. Am. Coll. Cardiol. 2006;48:e149–246).
The new consensus statement adopts for the ablation community the AF classification system developed in the 2006 ACC/AHA/ESC guidelines. Paroxysmal AF is defined as recurrent AF that terminates spontaneously within 7 days. Persistent AF is AF that is sustained beyond 7 days or lasts less time but necessitates cardioversion. Long-standing persistent AF is defined as continuous AF lasting more than 1 year.
The 2006 ACC/AHA/ESC guidelines were the first-ever revision to list ablation as a second-line treatment for AF. The ablation consensus panel agreed that in general catheter ablation shouldn't be considered first-line therapy and stated that the primary indication for the procedure is the presence of symptomatic AF refractory or intolerant to at least one class I or III antiarrhythmic drug. Surgical AF ablation is indicated for symptomatic AF patients undergoing other cardiac surgery, selected asymptomatic AF patients undergoing heart surgery in whom the ablation can be performed with minimal risk, and as a stand-alone operation in only limited circumstances, Dr. Calkins explained.
The expert panel recommended adherence to the anticoagulation guidelines listed in the 2006 ACC/AHA/ESC guidelines, with the added comment that patients in persistent AF at the time of ablation should have a transesophageal echocardiograph to screen for a thrombus.
Warfarin is recommended for at least 2 months post ablation. Decisions regarding its use beyond then should be based on the patient's stroke risk factors rather than the presence or type of AF. Continuation of warfarin is generally recommended in patients with a CHADS score of 2 or greater. A patient's wish to discontinue long-term warfarin is not an appropriate indication for ablation because there is not as yet convincing evidence that ablation safely allows this practice, according to Dr. Calkins.
The 2006 ACC/AHA update of clinical competence in invasive electrophysiology proposed a minimum of 30–50 AF ablation procedures (J. Am. Coll. Cardiol. 2006;48:1503–17). The expert consensus panel considered that too low to achieve a high degree of proficiency and cited evidence that outcomes are better at centers that have performed more than 100 ablations.