Teruhiko Terasawa, MD; Ethan M. Balk, MD, MPH; Mei Chung, MPH; Ann C. Garlitski, MD; Alawi A. Alsheikh-Ali, MD; Joseph Lau, MD; Stanley Ip, MD
Terasawa T, Balk EM, Chung M, Garlitski AC, Alsheikh-Ali AA, Lau J, et al. Systematic Review: Comparative Effectiveness of Radiofrequency Catheter Ablation for Atrial Fibrillation. Ann Intern Med. 2009;151:191-202. doi: 10.7326/0003-4819-151-3-200908040-00131
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Published: Ann Intern Med. 2009;151(3):191-202.
Atrial fibrillation is the most common sustained arrhythmia. Medical treatment often fails to control symptoms.
To compare the benefits and harms of radiofrequency catheter ablation and medical therapy in adults with atrial fibrillation.
MEDLINE and the Cochrane Central Register of Controlled Trials (2000 to December 2008) were searched for English-language reports of studies in adults.
6 independent reviewers screened abstracts to identify longitudinal studies of adults with atrial fibrillation who underwent radiofrequency catheter ablation. Studies reported arrhythmia or other cardiovascular outcomes at least 6 months after ablation or any adverse events.
Data were extracted by 1 of 4 reviewers and were verified by a cardiac electrophysiologist. Study quality and overall strength of evidence for each question were rated by 2 independent reviewers; disagreements were resolved by consensus.
108 studies met eligibility criteria. Moderate strength of evidence (3 trials; nÂ = 30 to 198) showed that radiofrequency ablation after a failed drug course was more likely than continuation of drug therapy alone to lead to maintained sinus rhythm. Low strength of evidence (4 trials [nÂ = 30 to 137] and 1 retrospective study [nÂ = 1171]) suggested that radiofrequency ablation improved quality of life, promoted avoidance of anticoagulation, and decreased readmission rates compared with medical treatment. Major adverse events occurred in fewer than 5% of patients in most of 84 studies.
Study follow-up was generally 12 months or less. Large heterogeneity of applied techniques and reporting of outcomes precluded many definitive conclusions. Reporting of adverse events was poor. Publication and selective reporting biases could not be ruled out. Studies with small samples and studies reported in a language other than English were excluded.
Radiofrequency catheter ablation is effective for up to 12 months of rhythm control when used as a second-line therapy for atrial fibrillation in relatively young patients with near-intact cardiac function. Longer studies that use primary end points of stroke and mortality are needed.
Is radiofrequency catheter ablation a better alternative than medical therapy for patients with atrial fibrillation?
This systematic review found that radiofrequency ablation after a failed drug course maintained sinus rhythm more often than continuation of drug therapy alone. Some studies found that ablation improved quality of life but did not necessarily reduce stroke rates compared with medical therapy. Fewer than 5% of patients undergoing ablation reportedly experienced major adverse events, such as pulmonary-vein stenosis or cardiac tamponade.
Most available evidence was obtained in middle-age adults with preserved left ventricular function and involved follow-up periods of 1 year or less.
RFA = radiofrequency catheter ablation.
* The RFA groups in 6 randomized, controlled trials and 2 nonrandomized studies that compared catheter ablation with medical treatment were used as cohorts.
† 56 studies met criteria for ≥2 questions.
The diamond shows the summary relative risk centered on a combined estimate and extending to 95% CIs. Squares and horizontal lines indicate relative risks and 95% CIs, respectively, for individual studies. The size of the squares is proportional to the weight of each study in the meta-analysis. Studies are ordered by sample size. AAD = antiarrhythmic drug; RFA = radiofrequency catheter ablation.
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