Mayo Clinic electrophysiologist
Christopher V. DeSimone, M.D., Ph.D., and cardiologist Kyle W. Klarich, M.D., review indications that an early rhythm-controlling approach for atrial fibrillation may be beneficial. Dr. DeSimone discusses ideal patients who may be candidates for first line cardiac ablation therapy.
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Atrial fibrillation as you know, is not inherently dangerous to the patient, but it impacts their quality of life severely. It's very important for patients to see a cardiologist early and then usually that leads to a referral to electrophysiology. If someone has atrial fibrillation, the longer atrial fibrillation occurs, the more likely it is to continue to occur and the harder it is to treat. The old studies. Data said if the patient is not having symptoms, make sure they have their rates controlled and their rates controlled would be equivalent in terms of mortality to someone that has a rhythm controlling approach such as ablation or even back then mostly drugs. Now, we have more and more data coming out that suggests there are certain patients that will do better with a rhythm controlling approach. And even if they do a rhythm controlling approach earlier on, and it makes sense because when you're taking a rhythm controlling approach, you're taking a patient that has atrial fibrillation, which we call paroxysmal at the early stage of it. And if you're treating and getting on it there, the technologies we have are much better, our success rates are much higher because those mainly involve the pulmonary veins as you start to go on through the atrial fibrillation spectrum where you start to say long standing proxy or persistent becomes much more difficult because there the horse is already out of the bar. Not only do you have the pulmonary veins, but you have the substrate. So it's not just the veins, but the atrial tissue itself changes and that our success rates are much lower. So when we turn to ablation at that time, yes, we could do it. But it's not as ideal as when we take a patient that was paroxysmal, we have to individualize care for each patient. We think about the ablation and medical therapy with anti arrhythmic drugs as being both first line therapies that are equivalent in a way. There are some nuances there, it comes down to patient preference and the patient itself. What are their comorbidities? Are they in heart failure? What are their symptoms? How long have they been in atrial fibrillation? It's not just a kind of one size fits all. There's an algorithm you basically go through when a patient's in front of you and you have that honest discussion about. Here's the risks. Here's the benefits, here's the pros and here's the cons catheter ablation as well as drugs. If the patient says to me, I'd prefer to take pills. I don't really want to have a surgery or a catheter in my body. I'll try that. But say the pills don't work or they're working of the time but not completely. Sometimes we add that extra layer on with a catheter based procedure to better control the atrial fibrillation. I think an excellent patient would be someone clearly that has symptoms that are tied to when they have atrial fibrillation. Another part who really is getting a benefit from what the recent trial data is showing are patients that have heart failure or a reduced ejection fraction, especially if we think that it's due to the atrial fibrillation. So we call this tachycardia induced cardiomyopathy. We make the effort to go beyond the diagnosis of atrial fibrillation to really understand what's underlying that. And then to address those problems before we jump ahead to the therapy, just as important, if not more important than catheter ablation and that's controlling everyone's risk factors. So getting your diabetes under control, getting your blood pressure under control, treating sleep apnoea screening for sleep apnoea, making sure patients are getting adequate exercise, adequate sleep, not too much caffeine or alcohol. All of these things come into play to say this is a patient that stands to have a good benefit from ablation therapy and a good outcome. What makes mayo special, really wrapped around the whole idea and intent of taking care of that patient as an individual, the knowledge that the people have the high volume, the studies that people in the echolab are doing around understanding atrial fibrillation, the collaboration of the echocardiographer with our electrophysiologists to really do a lot of research in those areas. If you have a patient with atrial fibrillation and you or the patient are considering catheter ablation or a rhythm controlling approach. We are always here and more than happy and willing to collaborate.