Atrial fibrillation ablation in end-stage renal Disease:...Yes, we can!

Abstract

Atrial fibrillation (AF) ablation has made giant strides over the last two decades, achieving the status of first-line therapy for symptomatic AF [1]. Radiofrequency ablation (RFA) and Cryoballoon ablation (CBA) have remained the mainstay energy sources for pulmonary vein isolation [2]. CBA is non-inferior to RFA in patients with paroxysmal drug-refractory AF [3]. With the increasing confidence of electrophysiologists, better tools, and promising results of durable pulmonary vein isolation, catheter ablation is frequently offered to patients who are not well-represented in clinical trials [4,5]. Patients afflicted with end-stage renal disease (ESRD) comprise one such growing subset. As high as a quarter of the patients on chronic hemodialysis are comorbid with AF [6]. Furthermore, AF confers an incremental mortality risk in patients with ESRD [7]. Yet major prospective randomized-controlled trials defining the merits of AF ablation have consistently excluded patients requiring hemodialysis [1,3,8]. There have been some retrospective studies that have ascertained catheter ablation outcomes using RFA in patients with ESRD, but the consequences of CBA in this cohort remain unidentified [7,9]. In the current issue of the Indian Pacing and Electrophysiology Journal, Hayashi et al. explore CBA and RFA in patients on chronic hemodialysis [10]. In their meticulously conducted retrospective study of 44 patients with AF on chronic hemodialysis, 21 underwent RFA, and 23 were subjected to CBA. The authors analyzed a composite endpoint including a documented recurrence of any atrial tachyarrhythmia (ATA) or a prescription of antiarrhythmic drugs. At a follow-up of one year, freedom from the composite outcome was achieved in 68.2% of patients in the CBA group than 58.4% of patients in the RFA group. The efforts of Hayashi et al. in pursuing AF ablation in this