Catheter Ablation For Cardiac Arrhythmias

Catheter ablation is a technique for eliminating cardiac arrhythmias by selectively destroying a portion of myocardium or conduction system tissue that contains the arrhythmogenic focus. A variety of different energy sources can be utilized with catheter ablation, such as radiofrequency and/or cryotherapy. Supraventricular Arrhythmia For individuals who have supraventricular arrhythmias who receive catheter ablation, the evidence includes a randomized controlled trial (RCT) and numerous case series and uncontrolled trials. Relevant outcomes are overall survival, symptoms, change in disease status, morbid events, medication use, and treatment-related morbidity. Clinical series of paroxysmal supraventricular tachycardia have reported very high success rates at well over 90%. Serious complications, mainly atrioventricular block requiring pacemaker insertion, occur in approximately 1% of patients. High success rates are also reported for atrial flutter and focal atrial tachycardia. There are few comparative or trial data. The RCT assessing catheter ablation of the accessory pathway confirmed that incidence of arrhythmic events is greatly reduced with catheter ablation. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome. Ventricular Arrhythmia For individuals with drug- and implantable cardioverter defibrillator (ICD)-refractory ventricular tachycardia (VT) due to structural heart disease who receive catheter ablation, the evidence includes RCTs and systematic reviews of RCTs. Relevant outcomes are overall survival, symptoms, change in disease status, morbid events, medication use, and treatment-related morbidity. Across 10 individual RCTs that compared catheter ablation with usual care (medical management) and 1 RCT that directly compared escalation of antiarrhythmic medications with catheter ablation in patients who had VTs and an automatic ICD, the evidence has shown that procedural success is 80% to 90%, and that catheter ablation is successful at reducing the number of VT episodes by about 30%. The evidence has further shown that catheter ablation is associated with approximately a 50% reduction in inappropriate ICD interventions compared with usual medical management alone. The rate of serious procedural adverse events is low. Late recurrences do occur, but most patients treated with ablation remain free of VT at 1- to 2-year follow-ups and 40% to 50% remain VT-free after 6 years of follow-up. The trial directly comparing catheter ablation with the escalation of medication found a 28% lower rate of a composite of death, VT storm, and appropriate ICD shock among patients undergoing catheter ablation vs those receiving an escalation in antiarrhythmic drug therapy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome. For individuals who have idiopathic VT refractory to drug therapy and ICD placement who receive catheter ablation, the evidence includes a few case series. Relevant outcomes are overall survival, symptoms, change in disease status, morbid events, medication use, and treatment-related morbidity. There are no comparative or trial data and, given the rarity of the disease, such RCTs are unlikely. Case series have reported high success rates and low adverse event rates with catheter ablation. However, the body of literature is small. The evidence is insufficient to determine the effects of the technology on health outcomes. For individuals who have VT storm who have failed pharmacologic treatment who receive catheter ablation, the evidence includes a few case series. Relevant outcomes are overall survival, symptoms, change in disease status, morbid events, medication use, and treatment-related morbidity. Serious complications have been reported at reasonably low rates, and mortality from the procedure was reported to be 0.6% in a meta-analysis of case series. There are no comparative or trial data. Because of the emergent nature of this condition, RCTs are not expected to be performed. In these situations, morbidity and mortality are expected to be extremely high in patients who have failed pharmacologic therapy; therefore, catheter ablation is expected to reduce morbidity and mortality. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome. Clinical input obtained in 2012 has supported the use of catheter ablation to treat VT and other ventricular arrythmias.