Sérgio Barra1, Jakub Baran2, Kumar Narayanan3, Serge Boveda4, Simon Fynn5, Patrick Heck5, Andrew Grace5, Sharad Agarwal5, João Primo6, Eloi Marijon7, Rui Providência8. 1. Cardiology Department, Papworth Hospital NHS Foundation Trust, Cambridge, UK. Electronic address: sergioncbarra@gmail.com. 2. Cardiology Department, Papworth Hospital NHS Foundation Trust, Cambridge, UK; Division of Clinical Electrophysiology, Department of Cardiology, Grochowski Hospital, Postgraduate Medical School, Warsaw, Poland. 3. Paris Cardiovascular Research Center, Paris, France; Cardiology Department, MaxCure Hospitals, Hyderabad, India. 4. Cardiology Department, Clinique Pasteur, Toulouse, France. 5. Cardiology Department, Papworth Hospital NHS Foundation Trust, Cambridge, UK. 6. Cardiology Department, V. N. Gaia Hospital Center, V. N. Gaia, Portugal. 7. Paris Cardiovascular Research Center, Paris, France; Cardiology Department, European Georges Pompidou Hospital, Paris, France; Paris Descartes University, Paris, France. 8. Barts Heart Centre, Barts Health NHS Trust, London, UK.
Abstract
BACKGROUND: Maintenance of sinus rhythm has been associated with lower mortality, but whether atrial fibrillation (AF) ablation per se benefits hard outcomes such as mortality and stroke is still debated. OBJECTIVE: To determine whether AF ablation is associated with a reduction in all-cause mortality and stroke compared with medical therapy alone. METHODS: Literature search looking for both randomized and observational studies comparing AF catheter ablation vs. medical management. Data pooled using random-effects. Risk ratios (RR) with 95% confidence intervals (CI) used as a measure of treatment effect. The primary and secondary outcomes were all-cause mortality and occurrence of cerebrovascular events during follow-up, respectively. RESULTS: Thirty studies were eligible for inclusion, comprising 78,966 patients (25,129 receiving AF ablation and 53,837 on medical treatment) and 233,990patient-years of follow-up. The pooled data of studies revealed that ablation was associated with lower risk of all-cause mortality: 5.7% vs. 17.9%; RR=0.44, 95% CI 0.32-0.62, p<0.001. In a sensitivity analysis by study design, a survival benefit of AF ablation was seen in randomized studies, with no heterogeneity (mortality risk 4.2% vs. 8.9%; RR=0.55, 95% CI 0.39-0.79, p=0.001, I2=0%), and also in observational studies, but with marked heterogeneity (6.1% vs. 18.3%; RR=0.39, 95% CI 0.26-0.59, p<0.001, I2=95%). The mortality benefit in randomized studies was mainly driven by trials performed in patients with left ventricular (LV) dysfunction and heart failure. The pooled risk of a cerebrovascular event was lower in patients receiving AF ablation (2.3% vs. 5.5%; RR=0.57, 95% CI 0.46-0.70, p<0.001, I2=62%), but no difference was seen in randomized trials (2.2% vs. 2.1%; RR=0.94, 95% CI 0.46-1.94, p=0.87, I2=0%). CONCLUSIONS: Ablation of atrial fibrillation associates with a survival benefit compared with medical treatment alone, although evidence is restricted to the setting of heart failure and LV systolic dysfunction.
BACKGROUND: Maintenance of sinus rhythm has been associated with lower mortality, but whether atrial fibrillation (AF) ablation per se benefits hard outcomes such as mortality and stroke is still debated. OBJECTIVE: To determine whether AF ablation is associated with a reduction in all-cause mortality and stroke compared with medical therapy alone. METHODS: Literature search looking for both randomized and observational studies comparing AF catheter ablation vs. medical management. Data pooled using random-effects. Risk ratios (RR) with 95% confidence intervals (CI) used as a measure of treatment effect. The primary and secondary outcomes were all-cause mortality and occurrence of cerebrovascular events during follow-up, respectively. RESULTS: Thirty studies were eligible for inclusion, comprising 78,966 patients (25,129 receiving AF ablation and 53,837 on medical treatment) and 233,990patient-years of follow-up. The pooled data of studies revealed that ablation was associated with lower risk of all-cause mortality: 5.7% vs. 17.9%; RR=0.44, 95% CI 0.32-0.62, p<0.001. In a sensitivity analysis by study design, a survival benefit of AF ablation was seen in randomized studies, with no heterogeneity (mortality risk 4.2% vs. 8.9%; RR=0.55, 95% CI 0.39-0.79, p=0.001, I2=0%), and also in observational studies, but with marked heterogeneity (6.1% vs. 18.3%; RR=0.39, 95% CI 0.26-0.59, p<0.001, I2=95%). The mortality benefit in randomized studies was mainly driven by trials performed in patients with left ventricular (LV) dysfunction and heart failure. The pooled risk of a cerebrovascular event was lower in patients receiving AF ablation (2.3% vs. 5.5%; RR=0.57, 95% CI 0.46-0.70, p<0.001, I2=62%), but no difference was seen in randomized trials (2.2% vs. 2.1%; RR=0.94, 95% CI 0.46-1.94, p=0.87, I2=0%). CONCLUSIONS: Ablation of atrial fibrillation associates with a survival benefit compared with medical treatment alone, although evidence is restricted to the setting of heart failure and LV systolic dysfunction.
Authors: Kevin Willy; Kristina Wasmer; Dirk G Dechering; Julia Köbe; Philipp S Lange; Nils Bögeholz; Christian Ellermann; Florian Reinke; Gerrit Frommeyer; Lars Eckardt Journal: Clin Cardiol Date: 2020-10-19 Impact factor: 2.882