According to Pasquale Santangeli (Texas Cardiac Arrhythmia Institute, St David’s Medical Center, Austin, USA) and others, as reported in a study published in the Journal of Cardiovascular Electrophysiology, radiofrequency catheter ablation of atrial fibrillation is a safe and effective treatment in patients aged 80 or older
Santangeli et al stated, “to the best of our knowledge”, that their study is the largest to date of the safety and long-term outcomes of radiofrequency catheter ablation in octogenarians. They reported that although up to 25% of strokes occurring in patients aged 80 or older can be attributed to atrial fibrillation, data for “potentially curative treatments” such as catheter ablation are lacking. Santangeli et al wrote: “Surprisingly, octogenarians have been largely excluded from trials evaluating the benefit of radiofrequency catheter ablation and current guidelines suggest a conservative approach with medical therapy in this patient population due to the lack of adequate clinical studies.”
From a database of 2,754 patients, they reviewed data for 103 octogenarians who underwent catheter ablation for drug-refractory atrial fibrillation between 2008 and 2011 and compared them with younger patients who underwent the same procedure. Santangeli et al did not find any differences in the rate of success of primary procedures (single procedures) between the octogenarian and younger cohorts (69% vs. 71%, respectively; p=0.65). They added that there was also no difference in success rates when patients were stratified by type of atrial fibrillation (paroxysmal, persistent, and long-standing persistent), reporting: “Specifically, in the subgroup of patients with paroxysmal atrial fibrillation, the procedural outcomes between octogenarians and younger patients were comparable (single-procedure success rate 65% vs. 78%, respectively, p=0.23) despite the fact that octogenarians with paroxysmal atrial fibrillation presented with a higher prevalence of non-pulmonary vein trigger sties, and required longer procedural time to effectively target such non-pulmonary vein areas.” According to Santangeli et al, “notably” there was a high prevalence of non-pulmonary vein triggers among octogenarian patients with paroxysmal atrial fibrillation and, as such, it was tempting to hypothesise that the underlying pathology of atrial fibrillation in older patients is different from younger patients.
As well as appearing to be effective in octogenarian patients, catheter ablation also appears to be safe–Santageli et al reported: “The rate of procedure-related complications was also not significantly different between the two age groups both analysing the overall sample of patients, and at subgroup analyses sorted by type of presenting atrial fibrillation (paroxysmal and non-paroxysmal atrial fibrillation).”
However, Michael Kim, Feinberg School of Medicine, Northwestern University, Chicago, USA, wrote in accompanying editorial that the patients in Santageli et al’s study were “highly selected and not typical of the multitude of octogenarians with atrial fibrillation” and added that, as a result, their data “must be interpreted with such considerations in mind”. Kim explained that the octogenarians, aside from their age, were nearly as “healthy” as the younger patients in the study. He wrote: “Despite the likely excellent functional and health status of an octogenarian undergoing catheter ablation of atrial fibrillation, ‘old is old’ and octogenarians are different than the mid 50- to 60-year-old patient traditionally undergoing atrial fibrillation ablation.” He added that until more robust data were available, it may be better for the treating physician to consider other forms of medicine for atrial fibrillation in this patient group. Kim said: “The threshold to offer catheter ablation of atrial fibrillation should be higher than in the more traditional, younger and healthier cohort of atrial fibrillation ablation candidates.”
Andrea Natale, one of the study’s investigators and executive medical director, Texas Cardiac Arrhythmia Institute, St David’s Medical Center, Austin, Texas, USA, told Cardiac Rhythm News that although a randomised controlled study on this would be good, it would be difficult. He said: “The number of octogenarian who are in good health are not many [as would be necessary for such a trial], but I believe this group of the population will increase. It is very important to emphasise that in this population, pulmonary vein isolation alone it is not enough.”