PMC:6019327 / 67457-71807 JSONTXT

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Benefits and Rationale for Eliminating AF with Ablation\nAs described earlier in this document, AF is associated with many adverse outcomes, including stroke, dementia, HF, impaired QOL, increased medical costs, and mortality. Understanding the effect of catheter ablation of AF on these outcomes is important in the overall assessment of the role of ablation in the long-term management of patients with AF. There have been a number of studies that have examined long-term outcomes with AF ablation. To date, however, none have prospectively randomized patients to ablation vs medical management and followed them longitudinally for more than 1 to 2 years. There are some long-term prospective registries of patients who have undergone AF ablation, with patients matched to those treated medically. Despite rigorous propensity matching, there could still be unrecognized differences in the populations treated with ablation compared with those receiving medical management. Thus, most of the evidence we have, while suggestive of benefit from ablation, cannot be taken as definitive with respect to major health outcomes. This lack is the rationale behind the Catheter Ablation vs Anti-arrhythmic Drug Therapy for Atrial Fibrillation Trial (CABANA) (ClinicalTrials.gov identifier NCT00911508), which is a prospective, randomized trial of ablation vs medical management of AF. The trial has completed enrollment, but it will be some time before the results are known.\nIt is widely recognized that AF ablation is effective in controlling AF and its associated symptoms. Multiple studies have demonstrated that AF ablation improves QOL in a patient with symptomatic AF, including those with HF.231,232 Many patients with AF have HF with reduced ejection fraction (EF). Multiple studies have examined the effect of ablation on EF.63,76,233,234,235,236 In a meta-analysis of nine studies of AF ablation in patients with HF, mean EF improved 11% (95% confidence interval [CI] 6.9–15.3, P \u003c.001).237 The effect of ablation on the future risk of stroke is of great interest, partly because of the morbidity and mortality associated with stroke, but also because of the need to inform decisions regarding continuing anticoagulation in patients with apparently successful ablations. A number of studies, but not all, have reported a low stroke rate in patients who have undergone AF ablation when followed long term.238,239,240,241,242 Although the results of these studies taken as a whole report a lower than expected stroke rate, these results can be considered preliminary data because many of these trials enrolled patients with a CHA2DS2-VASc score of \u003c2, in whom stroke rates will be anticipated to be low. This reflects the fact that very few patients with a high stroke risk profile were followed long term after suspension of anticoagulation. Notably, it has recently been shown that patients with PAF have a lower stroke rate than those with persistent AF.51 These observations, while preliminary, are supportive of the emerging belief that AF ablation could in fact reduce stroke risk. The ultimate proof that elimination of AF by ablation lowers stroke risk will require a large, prospective, randomized clinical trial such as CABANA. Limited studies have evaluated the effect of ablation on the risk of dementia. Prior studies have reported that Alzheimer’s dementia occurred in 0.2% of AF ablation patients compared with 0.9% of patients with AF who did not have ablation and 0.5% of patients without AF (P \u003c.0001). Other types of dementia were also reduced significantly in patients who had undergone ablation.239 Although these findings are of interest, they must be considered preliminary because this was not a prospective randomized trial. The impact of AF ablation on mortality is also uncertain. Although a number of preliminary studies have reported encouraging results, not all studies have reported a reduction in mortality. These results must also be considered preliminary due to their study design.232,239,241\nIn summary, there is strong evidence that AF ablation improves QOL, and reasonable evidence that AF ablation improves ventricular function in those patients with AF who have HF. The impact of AF control with ablation on other endpoints, including stroke risk, dementia, and mortality, will require further study."}