Introduction The outcome of persistent atrial fibrillation (PeAF) ablation remains suboptimal and procedures may be long and painful. Little evidence is available on outcome for procedures under general anaesthetic (GA) compared to conscious sedation (CS). We performed a single-centre observational study to assess whether use of GA in PeAF ablation improved outcome and was cost-effective.
Methods 292 patients undergoing first ablation procedures for PeAF by radio-frequency point-by-point technique under CS (n=220) or GA (n=72) were followed. End points were freedom from recurrence of atrial arrhythmia and freedom from listing for repeat ablation at 18 months. Clinical assessments, 12 lead ECGs and 24 hour Holter monitors were obtained at baseline and at 3, 6, 12 and 18 months.
Results Baseline characteristics were not significantly different between groups. Freedom from atrial arrhythmia was higher in patients under GA rather than CS (63.9% vs 42.3%, HR 1.87, 95% CI: 1.23 to 2.86, p=0.002) (figure 1A). There was no difference in procedure time and ablation time between groups. There were no complications resulting from use of GA; 5 cases under CS were hindered by airway problems, agitation or pain.
Significantly fewer GA patients were listed for repeat procedures (29.2% vs 42.7%, HR 1.62, 95% CI: 1.01 to 2.60, p=0.044 (figure 1B)). Of patients who had arrhythmia recurrence but did not undergo repeat ablation, main reasons were: only occasional recurrences of paroxysmal AF (PAF) (39%), feeling subjectively better despite continuing AF (20%), or low chance of success from further procedures (17%) (figure 2).
Multivariate Cox regression analysis found a higher freedom from atrial arrhythmia with use of GA, as well as for decreasing age, normal LA size and decreasing time in AF pre-procedure. Decreasing age and use of GA increased the likelihood of freedom from listing for repeat ablation. A PeAF procedure under GA in our institution is slightly more expensive than under CS (£4406.68 vs £4115.15), but due to lower redo rates, the cost after a maximum of two procedures is lower with GA, with an average saving of £178.88 per patient.
Conclusions Using GA to perform PeAF ablation is both clinically and financially effective.
Patient immobility leads to improved accuracy of mapping and catheter stability, and optimises lesion quality. Ablating during apnoea has been shown to improve contact force (1) and a single previous study has demonstrated better outcomes for paroxysmal AF ablation under GA (2). However GA may be of particular use for PeAF, where more extensive substrate ablation may be employed, procedures last longer and DCCV is often required.
- Atrial fibrillation
- Catheter ablation
- Health economics
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