Why Atrial Fibrillation Ablation Should Be Considered First-Line Therapy for Some Patients

Atrial fibrillation (AF) is an increasingly common disease that affects patient morbidity and mortality. To date, treatments of AF have been frustrating, serving at best to palliate this arrhythmia. AF ablation, on the other hand, has emerged as a promising new treatment strategy. In contrast to rate control or antiarrhythmic drugs, ablation offers the possibility of a lasting cure. When ablation was first described, it was prudently reserved as a “last-line” treatment for highly symptomatic patients who were refractory to all other options. However, over the past 5 years, many centers worldwide have been reporting high success rates and few complications with ablation. There is also an increasing consistency in the way in which the procedure is performed, although some of the tools may still differ. AF ablation has reached “prime time,” and it appears appropriate that we expand its indications.We believe that it is now appropriate to offer AF ablation as first-line therapy for selected patients in experienced centers. Here, we stress the importance of maintaining sinus rhythm, the poor efficacy of nonablative treatments, and the emergence of an effective and safe approach to AF ablation.Recently, the importance of maintaining sinus rhythm has been called into question. A few large clinical trials have been published comparing treatment strategies for AF. In particular, the AF Follow-up Investigation of Rhythm Management (AFFIRM),1 Rate Control Versus Electrical Cardioversion for AF (RACE),2 and Strategies for Treatment of AF (STAF)3 trials compared a strategy of rate control and a rhythm control approach using antiarrhythmic drugs. Using an intention-to-treat analysis, these trials concluded that there was no mortality difference between the 2 approaches and that, for the patients enrolled, a rate control approach may be adequate treatment for AF. However, it would be incorrect to extrapolate that sinus rhythm offers …