Selectivity: Whoreallyshould be offered AF ablations?
In this issue of Journal of Cardiovascular Electrophysiology, Samuel et al. report their findings on healthcare resource utilization change in a cohort of patients before and after catheter ablation for AF.3 Between April 1, 2005 and March 31, 2011, 1,556 patients in Québec were identified as the study cohort. These patients underwent AF catheter ablation, with run in data collected 24 months before ablation and follow-up data for at least 24 months after ablation. The authors found a progressive increase in healthcare utilization over the 24-month period leading up to the first ablation. Hospitalizations for AF and AF-related cardiovascular conditions were significantly reduced in the 12 months postablation compared with the 12 months preablation, as did ER and outpatient visits, cardioversions, and echocardiography. The decline in resource utilization extended to 24 months after index ablation. The study cohort had a mean age of 56.5 years, with relatively few comorbidities and a low mean CHA2DS2-VASc score of 1.2. Importantly, a separate analysis showed that an increase in healthcare utilization was seen in the 25% of patients who required repeat ablations. The most significant and sustained decline in healthcare utilization was seen in patients who required a single procedure within the first 2 years.
The present study by Samuel et al.3 corroborates prior data that reduction in healthcare resource utilization post catheter ablation for AF is most evident in patients who have the highest chance of a successful first procedure. Repeat ablations are associated with higher total medical cost, over and above the cost of additional procedures.2 Indication for the procedure, definition of procedure success, patient characteristics, and procedural quality all play a role in the likelihood of repeat procedures. If the indication for ablation is the assumption that maintenance of sinus rhythm can reduce strokes and mortality, then the definition of success would be highly dependent on AF recurrence, and the threshold for repeat ablation would be low. Currently, however, there are no large randomized controlled studies demonstrating that maintenance of sinus rhythm by ablation procedures reduces strokes or mortality. Reduction in healthcare utilization would not be expected if ablations were performed for this indication.