Solving the left side of the ablation equation
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Key takeaways:
- Ablation as a first-line strategy is the best option for some patients with atrial fibrillation.
- With the use of ablation procedures rising, innovation is occurring to improve their safety and efficiency.
For millions of patients who live with atrial fibrillation, early detection and treatment are essential because research shows that early, intensive management of AF reduces stroke, hospitalization and heart failure.
As the cardiology community continues to see more patients presenting with AF every year, electrophysiologists must leverage the latest innovations and approaches to help their patients.
Emerging alternative options
Historically, drug therapy was the standard first-line treatment for patients with AF. However, in approximately half of patients treated with antiarrhythmic drugs (AADs), AF recurs within a year of initial treatment. For the patient population that does not respond to AADs, alternative options are critically important to address this unmet treatment need.
One solution backed by mounting early intervention evidence in recent years is catheter ablation, a minimally invasive procedure that can be used when medication fails to control AF or if patients prefer a nonpharmacologic approach. Uniquely, cryoablation therapy (Arctic Front Advance, Medtronic) is the only catheter ablation therapy with an FDA indication for first-line procedures before trying medication. To break down the procedure, a balloon catheter is used to block, or ablate, abnormal electrical signals and stop them from causing AF.
We are currently using cryoablation with promising results, backed by rigorous studies demonstrating the benefits of cryoablation across more than 1 million patients worldwide.
Data from numerous studies like Cryo-FIRST, EARLY-AF, EAST-AFNET 4 and STOP AF First tell us that using ablation as the first-line strategy can be the optimal rhythm control solution for some patients. With the support of these landmark trials, it is encouraging that we no longer have to commit patients to medication indefinitely to control their AF. This can make all the difference for patients who are having trouble doing daily activities like walking up the stairs or facing other risk factors, but who do not want to take drugs.
We are also seeing younger patients who are otherwise healthy and active presenting with AF more often. This is an example of where we would consider a first-line cryoablation, rather than prescribing daily medications to a 40-year-old for the rest of their life.
Bridging the complexity of transseptal access
A catheter ablation is effective, but performing the procedure is not always straightforward. Transseptal access is a technique to reach the left side of the heart for an ablation, which is recognized as a technical and complex part of the procedure. Although a necessary step in each AF ablation procedure, its inherent risk could be dangerous to the patient.
When we started doing ablation to treat AF, we would often perform transseptal access using multiple sheaths, exchanging them out for ones better suited for each stage of the procedure. However, the frequent changing of the sheaths presents dangers to the patient that need to be taken very seriously. Sheath exchanges create the potential to introduce air bubbles, foreign bodies or clots into the left atrium, which can increase the risk for stroke. The less you change out devices, the lower the chances are of complications.
The evolution of ablation
As ablation procedures and devices on the market evolve and the prevalence of AF increases, there is a demand for devices that will allow operators to perform these procedures in the safest and most efficient ways possible. New technology has emerged to eliminate the need for separate sheaths to perform the transseptal puncture and deliver the ablation therapy (FlexCath Cross transseptal access system, Medtronic). This means less risk to the patient, reduced procedure times and less equipment used to complete the procedure.
This development is in keeping with how, due to the rise on AF ablation procedures, it has become more important to use solutions that dovetail both safety and efficiency. We need to strive to help make complex procedures safer for the patient and efficient to perform.
References:
- Andrade JG, et al. N Engl J Med. 2021;doi:10.1056/NEJMoa2029980.
- Kirchoff P, et al. N Engl J Med. 2020;doi:10.1056/NEJMoa2019422.
- Kuniss M, et al. Europace. 2021;doi:10.1093/europace/euab029.
- Wazni OM, et al. N Engl J Med. 2021;doi:10.1056/NEJMoa2029554.
- Wolf PA, et al. Stroke. 1991;doi:10.1161/01.str.22.8.983.
For more information:
Ilyas K. Colombowala, MD, FACC, FHRS, is a cardiac electrophysiologist at Houston Heart Rhythm in Houston. He can be reached at ilyas@colombowala.com.
Kevin M. Trulock, MD, is a cardiac electrophysiologist at Community Heart and Vascular in Indianapolis. He can be reached at ktrulock@ecommunity.com.
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