Cost-effectiveness of catheter ablation versus medical therapy for the treatment of atrial fibrillation in the United Kingdom.

INTRODUCTION: Research evidence has shown that catheter ablation is a safe and superior treatment for atrial fibrillation (AF) compared to medical therapy, but real-world practice has been slow to adopt an early interventional approach. This study aims to determine the cost effectiveness of catheter ablation compared to medical therapy from the perspective of the United Kingdom. METHODS: A patient-level Markov health-state transition model was used to conduct a cost-utility analysis. The population included patients previously treated for AF with medical therapy, including those with heart failure (HF), simulated over a lifetime horizon. Data sources included published literature on utilization and cardiovascular event rates in real world patients, a systematic literature review and meta-analysis of randomized controlled trials for AF recurrence, and publicly available government data/reports on costs. RESULTS: Catheter ablation resulted in a favorable incremental cost-effectiveness ratio (ICER) of £8614 per additional quality adjusted life years (QALY) gained when compared to medical therapy. More patients in the medical therapy group failed rhythm control at any point compared to catheter ablation (72% vs. 24%) and at a faster rate (median time to treatment failure: 3.8 vs. 10 years). Additionally, catheter ablation was estimated to be more cost-effective in patients with AF and HF (ICER = £6438) and remained cost-effective over all tested time horizons (10, 15, and 20 years), with the ICER ranging from £9047-£15 737 per QALY gained. CONCLUSION: Catheter ablation is a cost-effective treatment for atrial fibrillation, compared to medical therapy, from the perspective of the UK National Health Service.

Targeting nonpulmonary vein triggers during atrial fibrillation ablation: is the game worth the candle?

PURPOSE OF REVIEW: Triggers for atrial fibrillation are found outside the pulmonary veins in 12-20% of cases. The role of addressing these triggers during catheter ablations has not been well defined. Therefore, the aim of this review is to summarize the effect of ablation of nonpulmonary vein triggers in addition to pulmonary vein isolation across the spectrum of atrial fibrillation in patients receiving catheter ablation. RECENT FINDINGS: In paroxysmal atrial fibrillation, an inducible nonpulmonary vein trigger is an independent predictor of recurrence. These triggers are inducible by adenosine and isoproterenol infusion. Nonpulmonary vein triggers cause a significant proportion of atrial fibrillation recurrence seen during repeat procedure and addressing them decreases such recurrence. Targeting inducible nonpulmonary vein triggers also decreases recurrence in persistent atrial fibrillation and was associated with a 25-30% relative reduction in arrhythmia recurrence compared with pulmonary vein isolation alone. In persistent atrial fibrillation, the addition of left atrial appendage isolation was associated with 55% reduction in arrhythmia recurrence. There was no benefit to the empirical ablation of the superior vena cava and the addition of extensive linear lines. There was insufficient evidence to assess the effects of empirical ablation of the coronary sinus, crista terminalis, left atrial posterior wall and the vein of Marshall on arrhythmia recurrence. SUMMARY: Evidence suggests that the presence of an inducible nonpulmonary vein trigger is a strong predictor of arrhythmia recurrence. Efforts to detect and ablate nonpulmonary vein triggers are warranted. Further studies are required to fully identify the role nonpulmonary vein trigger ablation.

Noninvasive assessment of atrial substrate change after wide area circumferential ablation: a comparison with segmental pulmonary vein isolation.

BACKGROUND: The wide area circumferential ablation (WACA) approach to atrial fibrillation is thought to result in 'substrate modification' perhaps related to autonomic denervation. We examined this prospectively by comparing WACA and segmental pulmonary vein isolation (PVI) using noninvasive surrogate markers. METHODS: Heart rate variability (HRV) and signal averaged P wave (SAPW) data were derived from high-resolution (HR) recordings ('SpiderView' ELA Medical) made in sinus rhythm immediately before and 24 hours after ablation. RESULTS: Forty patients recruited (20 WACA; 20 PVI); cohorts were comparable. WACA caused marked SAPW change: P wave duration (PWD) (149[4.6] ms to 160[5.9] ms; P = 0.003), root mean square (RMS) (4.4[0.4]microV to 2.8[0.4]; P = 0.001) and energy content (30-150 Hz; 20.4 [3.6]microV(2)/s to 13.7[2.4]; P = 0.001). No significant change was seen after PVI. Heart rate increased after WACA and PVI (61.4 to 73.5 [P = 0.001]; 69.5 to 75.0 [P = 0.07], respectively). HRV was significantly influenced after WACA: low frequency power (LF) 5.7(0.4) to 3.6(0.4); P = 0.001), high-frequency power (HF) 4.6(0.4)-3.4(0.3); P = 0.024, and after PVI: LF 5.4(0.3) to 4.3(0.3); P = 0.024. HF: 4.4(0.4) to 3.0(0.4); P = 0.018). CONCLUSIONS: HR recordings exhibit change in HRV after WACA and PVI. Marked change in both HRV and SAPW is observed after WACA. SAPW variables provide a measure of atrial substrate change after WACA unrelated to autonomic denervation.

Indications and nonindications for ablation of atrioventricular conduction in the elderly: is it sensible to destroy normal tissue?

Atrial fibrillation is common in later life. The goals of therapy are maintenance/restoration of sinus rhythm and control of ventricular rate when atrial fibrillation occurs. The only nonpharmacologic therapy of proven benefit is atrioventricular junction ablation and pacing, but this approach is irreversible and requires clear guidelines for patient selection. In paroxysmal atrial fibrillation, ablation and pacing carries a high risk of progression to permanent atrial fibrillation within 6 months but is indicated only when at least two appropriate drug strategies have failed. In persistent atrial fibrillation, ablation and pacing will inevitably result in permanent atrial fibrillation; this may influence the decision for pacemaker type and the timing of the procedure. In permanent atrial fibrillation, there is clear evidence for benefit, especially in those with reduced left ventricular function. In conclusion, ablation and pacing offers symptomatic and functional benefit to patients with drug-refractory atrial fibrillation. Timing of the intervention relates to response to other pharmacologic therapy.