Despite the fact that physicians have been performing radiofrequency ablations (RFAs) since the 1990s, less than 1% of the atrial fibrillation (AF) patient population in the U.S. and Europe is offered catheter-based treatment. This percentage, however, will no doubt rise significantly over the next decade. According to research from The Advisory Board Cardiovascular Roundtable, the number of AF catheter cases in the U.S. will increase almost 100% between 2007 and 2012.

Demographic trends, advances in ablation treatment and diagnostic techniques, health reform and new research will further accelerate the acceptance of AF ablation as a primary treatment strategy. Several studies have shown that AF ablation has both clinical and cost advantages in comparison with anti-arrhythmic drug (AAD) therapy.

Wilber and colleagues published a prospective, multi-center, randomized study(1) comparing catheter ablation and AADs for treatment of patients with paroxysmal AF who had previously failed at least one AAD therapy. At the end of the 9-month trial period, 66% of patients in the catheter ablation group remained free from treatment failure, compared with 16% of patients treated with AAD. Moreover, patients in the catheter ablation group had lower complication rates.

These findings are consistent with other research indicating that, compared to AAD, catheter ablation treatment for paroxysmal AF results in a longer time to treatment failure and improved quality of life. The Radiofrequency Ablation versus AADs for Atrial Fibrillation Treatment study(2) demonstrated that at 1-year follow-up, 87% of ablated patients were arrhythmia free compared to 47% for those on drug therapy.

Other research is dispelling the common misconception that ablations are more costly than drug therapy. A Canadian study in the Journal of Cardiovascular Electrophysiology(3) found that RFA as a first-line treatment in patients with symptomatic paroxysmal AF was cost neutral compared to AAD two years after ablation treatment.

Another study from Circulation: Arrhythmia and Electrophysiology(4) found that over a 5-year period, the cumulative costs with ablation and AAD were $26,484 and $19,898, respectively. The ablated patients, however, scored higher than those on AAD in regards to quality-adjusted life expectancy, which resulted in RFA being incrementally more cost-effective than AAD per quality-adjusted life-year. The authors concluded that, “RFA with or without AAD for symptomatic, drug-refractory paroxysmal AF appears to be reasonably cost-effective compared with AAD therapy alone from the perspective of the U.S. health care system, based on improved quality of life and avoidance of future health care costs.”(4)

A major obstacle preventing catheter ablation from becoming a primary treatment option for AF patients is the absence of results from prospective, randomized morbidity and mortality studies. Two studies now underway (CABANA and CASTLE-AF) could resolve this issue and further improve acceptance of catheter ablation within the medical community.

References
1. Wilber DJ, Pappone C, Neuzil P, et al. Comparison of antiarrhythmic drug therapy and radiofrequency catheter ablation in patients with paroxysmal atrial fibrillation: A randomized controlled trial. JAMA 2010;303:333–40.
2. Wazni O, Marrouche NF, Martin DO, et al. Randomized study comparing combined pulmonary vein-left atrial junction disconnection and cavotricuspid isthmus ablation versus pulmonary vein-left atrial junction disconnection alone in patients presenting with typical atrial flutter and atrial fibrillation. Circulation 2003;108:2479–83.
3. Khaykin Y, Wang X, Natale A, et al. Cost comparison of ablation versus antiarrhythmic drugs as first-line therapy for atrial fibrillation: an economic evaluation of the RAAFT pilot study. Journal of Cardiovascular Electrophysiology 2009;20(1):7.
4. Reynolds MR, Zimetbaum P, Josephson ME, et al. Cost-Effectiveness of Radiofrequency Catheter Ablation Compared With Antiarrhythmic Drug Therapy for Paroxysmal Atrial Fibrillation. Circulation: Arrhythmia and Electrophysiology 2009;2(4):362-369.

Nassir F. Marrouche, MD is the Executive Director of the Comprehensive Arrhythmia Research & Management Center, Director of Electrophysiology Laboratories, and Director of the Atrial Fibrillation Program at the University of Utah School of Medicine, Division of Cardiology.