AFib affects 6 million lives in the US.1 Each year ~350,000 patients undergo an ablation procedure to treat this condition. Intracardiac AFib ablation carries significant risk. In particular, complications associated with the transeptal puncture and esophageal fistulas are associated with significant cost to the healthcare system and the patient. Unfortunately, about 50% of AFib patients who undergo their first ablation procedure experience reoccurrence of AFib2 within one year. There are multiple theories on the underlying reasons for this huge variance in the outcome – with much dialogue and effort focusing on the procedure itself. Recently, new data published has suggested one of the gaps may not be in the ablation lines but in another condition—sleep apnea and the implications it has on the heart tissue and physiology.
There has been a recent uptick in new clinical studies that show the effect of sleep apnea on AFib recurrence. In March 2017 the American College of Cardiology was invited to review a paper discussing the evidence demonstrating the causal relationships between sleep apnea and higher AFib burden. Figure A is a recreation of a similar diagram featured in that publication. In light of this information, Dr. Elad Anter of the Boston Beth Israel Deaconess Medical Center and Harvard Medical Institute recently published a clinical study that may change the electrophysiologist’s (EP’s) approach to AFib ablation.
In this multi-center, prospective, randomized study, two groups, each of 43 patients, with Paroxysmal Atrial Fibrillation were studied: group one with diagnosed OSA and group two without OSA. The diagnosis was done both with traditional means and with the novel WatchPAT® home sleep test technology. All patients underwent comprehensive mapping of their atrial substrate, PV trigger identification and PV Isolation, and non-PV trigger mapping and ablation. In addition, there were two retrospective control groups, one without OSA and one with moderate OSA. Both of those groups underwent PVI alone without mapping and ablation of Non-PV triggers.
The findings of the study were amazing. After PV isolation, patients with OSA had significantly increased incidence of clinically relevant, additional Non-PV triggers (41.8% vs. 11.6%; P=0.003). Patients with OSA who only underwent PV isolation without ablating non-PV triggers had increased risk of arrhythmia recurrence (83.7% vs. 64.0%; P=0.003). Also, 1-year arrhythmia-free survival was similar between patients with and without OSA who underwent both PVI and non-PV triggers ablation (83.7% vs 81.4%; P=0.59).3
In conclusion, OSA is associated with structural and functional remodeling and an increased incidence of non-PV triggers. Eliminating these triggers will improve arrhythmia free survival. In other words, patients with OSA have a higher chance to have non-PV triggers and therefore require a different approach to AFib ablation.3 Knowing the patient’s OSA status prior to the ablation process will become a critical piece of information that may help to define the right ablation strategy.
- Seet et al. 2010 “Obstructive Sleep Apnea: Preoperative Assessment” Anesthesiology Clin 28 (2010) 199-215.
- Chinitz et al. 2015 “Effect of Obstructive Sleep Apnea Treatment on Atrial Fibrillation Recurrence: A Meta-Analysis” JACC: Clinical Electrophysiology Vol. 1, No. 1-2, March/April 2015: 41-51.
- Anter et al. “Circulation: Arrhythmia and Electrophysiology,” 10(11):e005407, NOV 2017.