Should Ablation Be First-Line Therapy for Patients with Paroxysmal AF?

Atrial fibrillation is the most common cardiac arrhythmia and the number of patients is expected to continuously increase in the next years. Catheter ablation is an effective, safe, and well-established treatment for patient with symptomatic and drug-resistant paroxysmal atrial fibrillation (PAF). Over the last decade, there was an increasing body of evidence demonstrating superiority of catheter ablation over antiarrhythmic drugs (AADs) in maintaining sinus rhythm. However, randomized clinical trials have not been conclusive to consider catheter ablation as a first-line therapy for PAF. The encouraging results of RAAFT Trial were not confirmed in the MANTRA-PAF Trial and in the RAAFT-2 Trial. Recent meta-analyses showed that catheter ablation is more effective than AAD therapy as a first-line treatment for PAF. In particular, relatively young patients and patients with no or minimal cardiovascular disease are the subpopulation that benefitted more from catheter ablation. On the other hand, the meta-analysis showed that catheter ablation causes more severe side effects than AAD therapy, underling the importance of patient selection and operator experience. To date, there are no univocal evidences to consider catheter ablation as a first-line therapy for PAF. Apart from patients' preference and avoidance of toxicity of AADs, the published data are supportive to consider a first-line catheter ablation in a peculiar subpopulation of patients. In particular, younger patients, patients with sinus node dysfunction related to AF, and patients with tachycardiomyopathy are the subgroups that seem to be good candidates for catheter ablation as a first-line therapy for PAF.