Fibrillation atriale. 10 ablation (2016)

Ablation d’une fibrillation atriale

Cette technique repose sur l’exclusion des quatre veines pulmonaires à l’origine de certaines FA paroxystiques. Elle est longue et difficile, réservée aux centres très spécialisés (il faut réaliser un cathétérisme trans septal pour positionner les sondes dans l’oreillette gauche puis dans les veines pulmonaires, une par une).

Voir Ablation d’une FA : technique

 

Indications ESC 2016  (voir tableau)

Kirchhof P, Benussi S, Kotecha D, et al; ESC Scientific Document Group. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016 ;37(38):2893-2962.

Version anglaise :

  • « Catheter ablation of symptomatic paroxysmal AF is recommended in patients who have symptomatic recurrences of AF on antiarrhythmic drug therapy (amiodarone, dronedarone, flecainide, propafenone, sotalol) and who prefer further rhythm control therapy, when performed by an electrophysiologist who has received appropriate training and is performing the procedure in an experienced centre. » (IA)
  • Catheter ablation of AF should be considered as first-line therapy to prevent recurrent AF and to improve symptoms inselected patients with symptomatic paroxysmal AF as an alternative to antiarrhythmic drug therapy, considering patient choice, benefit, and risk. (IIa)
  • AF ablation should be considered in symptomatic patients with AF and heart failure with reduced ejection fraction to improve symptoms and cardiac function when tachycardiomyopathy is suspected. (IIa)
  • ………….;

Version résumée française :

  • FA paroxystique récidivante et symptomatique sous antiarythmiques (IA) ou en première intention (IIA).
  • FA symptomatique pour une insuffisance cardiaque avec FEVG altérée possiblement rythmique (pour améliorer les symptômes et la FEVG) IIA
  • FA persistante réfractaire aux antiarythmiques (pour améliorer les symptômes (IIA)
  • Pour éviter l’implantation de stimulateur si bradycardie liée à la FA (IIA)

Efficacité

L’ablation offre une prévention efficace des récidives de FA (indications : voir figures) [1], par l’isolation des foyers initiateurs de la FA [formes paroxystiques brèves (< 24 h); lambeaux de FA entrecoupés de RS avec ESA précoces (P sur T) isolées ou en salves; activité atriale relativement monomorphe suggérant une forme focale, absence de cardiopathie; absence de dilatation de l’oreillette gauche en faveur d’une atteinte du substrat atrial : etude MANTRA-PAF].

Elle offre une prévention efficace des récidives (rémission > guérison), mais variable selon l’ancienneté de la FA (meilleure si paroxystique que persistante ou FA d’ancienneté < 2 ans), le nombre de procédures réalisées (souvent deux à trois), la correction des facteurs de risque associés (surcharge pondérale, apnée du sommeil…), l’adjonction d’un traitement antiarythmique, et surtout la durée et la méthode de surveillance des récidives…. Elle ne dispense pas d’une anticoagulation au long cours dans la majorité des cas.

Cet article résume le bénéficie de l’ablation sur le traitement antiarythmique dans une étude randomisée sur 2204 patients et suivi sur une durée médiane 48 mois.

Packer and al. Effect of Catheter Ablation vs Antiarrhythmic Drug Therapy on Mortality, Stroke, Bleeding, and Cardiac Arrest Among Patients With Atrial Fibrillation: The CABANA Randomized Clinical Trial. JAMA. 2019 Mar 15. (téléchargeable)

–> Among patients with AF, the strategy of catheter ablation, compared with medical therapy, did not significantly reduce the primary composite end point of death, disabling stroke, serious bleeding, or cardiac arrest

–> Yves Rosenberg, the program officer for the study said  : « When we examined the data according to the treatment actually received, the ablation group (half of the initial population minus 9% who did not receive ablation plus 27.5% of the drug group) had significantly lower rates of death as well as the combination of death, disabling stroke, serious bleeding, or cardiac arrest compared with patients who only received drug therapy ».

–> Yves Rosenberg, M.D. : “While data from the trial did not show that ablation was superior to drug therapy in reducing rates of deaths and strokes, it showed reduced recurrence of atrial fibrillation, as well as reductions in hospitalizations,” –> By the end of the study, however, there had been a significant decrease in symptoms – with only 25 % patients in the ablation arm reporting symptoms compared to 35 % patients treated with drug therapy alone (and 85 % during the previous month)

Edito –> For patients with symptoms, in whom quality of life is impaired by AF, catheter ablation can improve quality of life to a greater extent than drug therapy. However, patients who choose drug therapy will also likely experience significant improvements in quality of life and have no worse risk for the most concerning complications of AF, stroke and death. Thus, there is no mandate for these patients to undergo catheter ablation at this time. Catheter ablation may also have the added benefits of reducing AF burden and cardiovascular hospitalizations. However, it is important to note that more than 50% of patients randomized to ablation had a recurrence of AF over 4 years, and some of these patients may require repeat ablations in the future. Also, because patients with stroke risk factors continued to receive anticoagulation therapy as per guidelines, it remains unknown whether anticoagulation can be safely stopped in such patients even in the setting of a successful ablation.