Systematic Review: Comparative Effectiveness of Radiofrequency Catheter Ablation for Atrial Fibrillation

Background: Atrial fibrillation is the most common sustained arrhythmia. Medical treatment often fails to control symptoms. Purpose: To compare the benefits and harms of radiofrequency catheter ablation and medical therapy in adults with atrial fibrillation. Data Sources: MEDLINE and the Cochrane Central Register of Controlled Trials (2000 to December 2008) were searched for English-language reports of studies in adults. Study Selection: 6 independent reviewers screened abstracts to identify longitudinal studies of adults with atrial fibrillation who underwent radiofrequency catheter ablation. Studies reported arrhythmia or other cardiovascular outcomes at least 6 months after ablation or any adverse events. Data Extraction: Data were extracted by 1 of 4 reviewers and were verified by a cardiac electrophysiologist. Study quality and overall strength of evidence for each question were rated by 2 independent reviewers; disagreements were resolved by consensus. Data Synthesis: 108 studies met eligibility criteria. Moderate strength of evidence (3 trials; n = 30 to 198) showed that radiofrequency ablation after a failed drug course was more likely than continuation of drug therapy alone to lead to maintained sinus rhythm. Low strength of evidence (4 trials [n = 30 to 137] and 1 retrospective study [n = 1171]) suggested that radiofrequency ablation improved quality of life, promoted avoidance of anticoagulation, and decreased readmission rates compared with medical treatment. Major adverse events occurred in fewer than 5% of patients in most of 84 studies. Limitations: Study follow-up was generally 12 months or less. Large heterogeneity of applied techniques and reporting of outcomes precluded many definitive conclusions. Reporting of adverse events was poor. Publication and selective reporting biases could not be ruled out. Studies with small samples and studies reported in a language other than English were excluded. Conclusion: Radiofrequency catheter ablation is effective for up to 12 months of rhythm control when used as a second-line therapy for atrial fibrillation in relatively young patients with near-intact cardiac function. Longer studies that use primary end points of stroke and mortality are needed.