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Catheter ablation should not be first-line therapy for atrial fibrillation

Nature Clinical Practice Cardiovascular Medicine volume 4, pages 4–5 (2007)Cite this article

Catheter ablation therapy for atrial fibrillation (AF) has evolved rapidly from a highly experimental, unproven procedure, to its current status as the most common ablation procedure performed in most major hospitals throughout the world. This dramatic and widespread acceptance of catheter ablation of AF has been fueled by several factors, including a large number of studies that have reported high rates of successful treatment and a low incidence of complications, and the lack of satisfaction, from both patients and cardiologists, with available antiarrhythmic drug therapy.1,2 Recently, it has been proposed that catheter ablation should be considered as first-line therapy in the treatment of some patients with AF.3 The purpose of this Viewpoint article is to share my contrasting and strong belief that it is premature to consider catheter ablation of AF as first-line therapy.

There are three main points I would like to make in considering this issue. First, the true efficacy of catheter ablation of AF remains unknown; to date, there have been no large, prospective, multicenter clinical trials testing this technique. Although there have been more than 100 studies published on catheter ablation of AF, they have many limitations: most are single-center, nonrandomized experiences; the use of antiarrhythmic drugs and methods of monitoring patients postablation differ tremendously between studies; definitions of successful ablation vary and change over time, even within studies based at the same center; and the outcomes reported are commonly derived from a large subset of patients undergoing repeat ablation, which prevents determination of the single-procedure success rate. Furthermore, there are wide variations in the reported efficacy and complication rates, and the duration of follow-up has been less than 12 months in almost all of the studies performed so far. It is also notable that to date no randomized study has evaluated the impact of catheter ablation of AF on survival, although this end point will be evaluated as part of the upcoming CABANA (Catheter Ablation versus Anti-Arrhythmic Drug Therapy for Atrial Fibrillation) trial, which has just initiated its pilot phase.

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  1. The Johns Hopkins Hospital, 600 North Wolfe Street, Carnegie 530, Baltimore, MD 21287, USA hcalkins@jhmi.edu

Authors and Affiliations

  1. H Calkins is a Professor of medicine at the Johns Hopkins University School of Medicine and Director of the Electrophysiology Laboratory at the Johns Hopkins Hospital, Baltimore, MD, USA.,

    Hugh Calkins

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Competing interests

The author has acted as a consultant for Ablation Frontiers, Biosense, and Prorhythm. He has received lecture honoraria from Biosense, CR Bard and Guidant, and has received research support from Biosense and Guidant.

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Calkins, H. Catheter ablation should not be first-line therapy for atrial fibrillation. Nat Rev Cardiol 4, 4–5 (2007). https://doi.org/10.1038/ncpcardio0741

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