Post-ablation corticosteroid therapy

HARTFORD, CONNECTICUT. There is ample evidence that myocardial inflammation is a common sequel to radiofrequency (RF) catheter ablation for the purpose of curing atrial fibrillation (AF). It is also well established that as many as 40% of patients undergoing RF ablation experience early recurrence of AF before they even leave the hospital following their procedure. Early recurrence, in turn, has been linked to a poorer long-term outcome.

A group of electrophysiologists at the Hartford Hospital in Connecticut now report that treatment with intravenous antiinflammatory agents (corticosteroids) immediately after RF ablation and for the following 48 hours substantially reduce the incidence of early recurrence. Their study included 68 patients with paroxysmal (56%) or persistent (44%) AF most of whom had no underlying heart disease. The patients all underwent an anatomically-guided pulmonary vein isolation procedure with concomitant use of electrophysiologic mapping. Thirty-seven patients received 6 intravenous injections each containing 4 mg of dexamethasone over a 48-hour period post-ablation with the first injection given within 6 hours following completion of the procedure. Another 31 patients (control group) received no post-procedure corticosteroids or other antiinflammatories. All patients also received antiarrhythmics following the procedure.

During the hospital stay (an average of 3 days), 16 patients (23.5%) experienced an early recurrence of AF defined as an episode lasting longer than 10 minutes. Patients who had received dexamethasone had an 82% reduction in their odds of experiencing early recurrence. For each milligram of dexamethasone equivalent administered a 17% reduction in the odds of experiencing early recurrence occurred. Older age and prior use of digoxin, on the other hand, were found to increase the likelihood of early recurrence, while type of AF (paroxysmal or persistent) did not affect the odds of experiencing early recurrence.

The authors conclude that the administration of intravenous dexamethasone post-ablation substantially reduces the risk of early recurrence of AF and may result in an improved long-term outcome.

Sood, NA, Clyne, CA, et al. Intravenous corticosteroid use is associated with reduced early recurrence of atrial fibrillation immediately following radiofrequency catheter ablation. Journal of Atrial Fibrillation, Vol. 2, No. 7, September 2011

Editorís comment: A group of researchers from the University of California (San Francisco) found that ablatees with early recurrence were 21 times more likely to have elevated levels of C-reactive protein, a powerful indicator of inflammation, than were patients with no early recurrence.[1] Thus, it clearly makes sense to make a concerted effort to deal with post-ablation inflammation. A recent randomized trial reported by a group of Japanese researchers concluded that post-ablation corticosteroid therapy decreased the incidence of both early (7% vs 31%) and 14-month recurrence (29% vs 15%) in a group of 125 paroxysmal afibbers randomized to corticosteroid (hydrocortisone and prednisolone) therapy or placebo.[2]
[1] McCabe, JM, et al. Protracted CRP elevation after atrial fibrillation ablation. Pacing and Clinical Electrophysiology, Vol. 31, 2008, pp. 1146-51
[2] Koyama, T, et al. Prevention of atrial fibrillation recurrence with corticosteroids after radiofrequency catheter ablation. Journal of the American College of Cardiology, Vol. 56, 2010, pp. 1463-72