Catheter Ablation of Atrial Fibrillation: Will It Reduce Your Risk of Death, Serious Bleeding or Stroke?

The wide-spread public conception that catheter ablation cures atrial fibrillation and reduces one’s risk of stroke or dying has fueled a  $4.5 billion industry.  Until very recently there were no published randomized trials supporting this expensive and risky procedure.

The recently published landmark CABANA trial found that in patients with afib “the strategy of catheter ablation, compared with medical therapy, did not significantly reduce the primary composite end point of death, disabling stroke, serious bleeding, or cardiac arrest. ”

So there is no proven benefit of ablation on death, stroke, bleeding or cardiac arrest. This means that a medical management approach to management of afib is always an acceptable approach. Especially an enlightened medical approach.

In CABANA, women and those patients >75 years of age did worse with ablation as this chart shows.

What about complications? I mentioned that ablation was risky and this is because any time you put a catheter in someone’s heart you can create life-threatening problems. When you then heat up the tip of that catheter it is possible to burn/damage/destroy things that  are not your target.

As John Mandrola has pointed out at least ablation was not more dangerous than medical management:

A reassuring finding of CABANA was that ablation did not do worse than drugs. But one of the messages I heard from HRS was that CABANA showed that AF ablation is safe. This is a problem.

The complications in the ablation arm were more serious and more numerous than those in the drug arm. We will have to wait for the published paper for formal comparisons.  CABANA likely represents a best-case scenario because it allowed only experienced operators and centers to be part of the trial. Many people undergo ablation by less experienced operators.

Another important safety issue is the asymmetry of procedural complications. When you talk privately with ablation doctors, many, perhaps most, relay the story of a tragic death of an otherwise healthy middle-aged adult from an atrial-esophageal fistula.

Yes. A well-recognized and highly feared complication of ablation , atrial-esophageal fistula, causes rapid death due to exsanguination through a channel between the left atrium and the esophagus which develop due to destruction/burning of the normal esophageal/atrial tissue.

In this chart taken from the CABANA abstract presentation you can see the complications which do not include a highly feared atrial-esophageal fistula.

 

Can Catheter Ablation Improve Quality of Life?

Basically, after the CABANA trial we have no evidence that ablation will  improve hard outcomes in afib patients. However, there are numerous patients who feel they have greatly benefited from the procedure, experiencing years of afib free existence.

This benefit of ablation, of improving quality of life and making patients feel better is important.

The CABANA trial also looked at quality of life and in part II of this article I’ll examine that in detail.

Skeptically Yours,

-ACP


Update 6/12/2019 357 PM.

Twitter follower @mrice5025 was kind of enough to read the above closely enough to realize that the number of atrial esophageal fistulae was actually zero in the CABANA trial and I have corrected the text accordingly.

I have seen a case of this mostly fatal complication in a patient who had an ablation done at an outside hospital 5 weeks earlier and who rapidly died from it and I try to be very aware of its possibility as early diagnosis and surgery is the key to survival.

This review article gives an overview:

AF ablation carries a small risk of complications with the most serious being atrioesophageal fistula (AEF). Although the incidence is less than 0.1%, it is usually fatal Esophageal perforation or fistula was reported in 31 patients (0.016%) in the Global Survey of Esophageal and Gastric Injury in Atrial Fibrillation study. Symptom onset for esophageal perforation or fistula was reported on average 19.3 days after the ablation procedure but could appear as short as 6 days and as long as 59 days post ablation.Esophageal injury has been observed most frequently with percutaneous radiofrequency ablation, although it has also been reported with other energy sources including cryoablation,high-intensity focused ultrasound and even surgical ablation.

 


The featured image comes from this Cleveland Clinic video which has some great graphics and reasonable information (once you get by the annoying lady at the beginning who describes ablation as “an excellent minimally invasive” procedure.)

At my hospital, St. Luke’s, I have three outstanding electrophysiologists who do excellent ablations,, Jonas Cooper, Cary Fredman, and Mauricio Sanchez.

11 thoughts on “Catheter Ablation of Atrial Fibrillation: Will It Reduce Your Risk of Death, Serious Bleeding or Stroke?”

  1. But, is ablation safe and effective for atrial flutter? And will ablating aflutter reduce the chances of subsequent aging?

    1. Ablation is much more effective and safe for atrial flutter than it is for fib.
      I am unaware of any evidence to suggest, however, that ablation reduces aging.
      However, flutter and fib frequently coexist, and it is not uncommon for fib to emerge after a flutter ablation.

      1. Thank you. My mistake: Meant to ask if ablating aflutter will reduce (or increase) the chance of developing afib. (Not aging.)

  2. Can you discuss atrial natriuretic peptide and it’s effects as a result of atrial fibrillation?
    Does it vary from symptomatic AF to less symptomatic?
    Paroxysmal to sustained?
    AF treated medicinally vs by ablation?
    Tough on kidneys, is it not?
    Tough on QOL, no?

  3. I would like to know how much radiation is used when having a cardiac ablation. I’m concerned since I’ve already had radiation therapy for breast cancer.

    1. Yes. Your question prompted me to reach out to Dr. Mauricio Sanchez. He tells me he has been doing radiation-free ablations for AF for the last 5 years. I’m going to interview him for a post on the topic. He’s quite passionate about the dangers of radiation in EP labs for patients, operators and staff.

  4. Probably worth clarifying that atrio-esophageal fistula actually results in the reverse-direction flow, from esophageal lumen into the left atrium. As such, it does not result in rapid death due to exsanguination, but generally a much slower process, initially presenting as sepsis, with or without neurological findings, which are a result of debris, bacteria, and air, transiting from esophagus into the systemic circulation (including emboli to the brain, in many cases). This presentation, from a couple of weeks to a couple of months after the procedure, is particularly difficult to diagnose as atrio-esophageal fistula, since patients don’t necessarily report the previous procedure (they’re quite sick, so shouldn’t be expected to do so in that condition), and the presentation looks to most practitioners like typical sepsis, albeit without clear source until much more aggressive workup is pursued.

    1. Thanks for the clarification. Very important for clinicians to consider this entity in any patient with a sepsis-like picture presenting within a few months of an ablation.The patient that I diagnosed with it presented with a sepsis-like picture but also had hematemesis.

      1. Very interesting, thanks for the additional data. Perhaps it helped with the diagnosis to have the hematemesis, but I wonder what the prognostic implications are (if any) of having it (i.e., does the implied elevation in right atrial pressure correlate to a physiologic change that alters outcome in any way?).

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