AV nodal ablation and pacemaker implantation improves hemodynamic function in atrial fibrillation

Atrioventricular node ablation for atrial fibrillation in the era of conduction system pacing

Despite key advances in catheter-based treatments, the management of persistent atrial fibrillation (AF) remains a therapeutic challenge in a significant subset of patients. While success rates have improved with repeat AF ablation procedures and the concurrent use of antiarrhythmic drugs, the likelihood of maintaining sinus rhythm during long-term follow-up is still limited. Atrioventricular node ablation (AVNA) has returned as a valuable treatment option given the recent developments in cardiac pacing. With the advent of conduction system pacing, AVNA has seen a revival where pacing-induced cardiomyopathy after AVNA is felt to be overcome. This review will discuss the role of permanent pacemaker implantation and AVNA for AF management in this new era of conduction system pacing. Specifically, this review will discuss the haemodynamic consequences of AF and the mechanisms through which 'pace-and-ablate therapy' enhances outcomes, analyse historical and more recent literature across various pacing methods, and work to identify patient groups that may benefit from earlier implementation of this approach.

Atrial Fibrillation in Hypertrophic Cardiomyopathy: Diagnosis and Considerations for Management

Atrial fibrillation is common in hypertrophic cardiomyopathy with a prevalence of 22-32 %. The impact of atrial fibrillation on overall survival, left ventricular function, thromboembolic stroke and quality of life is crucial. This review enlightens incidence, pathophysiology, and clinical symptoms. Early recognition of atrial fibrillation is essential. Monitoring methods for early detection are described. Finally effective therapy options are discussed including oral anticoagulation and the role of interventional catheter-based ablation in the treatment of atrial fibrillation in HCM patients.

Quality of life in patients with atrial fibrillation: how to assess it and how to improve it

Atrial fibrillation (AF) is the most frequent cardiac rhythm disorder and presents a considerable public health burden that is likely to increase in the next decades due to the ageing population. Current management strategies focus on the heart rate and rhythm control, thromboembolism prevention, and treatment of underlying diseases. The concept of quality of life (QoL) has gained significant importance in recent years as an outcome measure in AF studies evaluating therapeutic interventions and as a relevant component of a comprehensive treatment plan. Quality of life is impaired in the majority of patients with AF, and both rate and rhythm control strategies show significant improvement in QoL measures in highly symptomatic patients. This article reviews generic and specialized instruments for measuring QoL in the context of AF, discusses their applications and limitations to integration in clinical practice, and addresses the potential of early therapy for improving QoL outcomes. The development and validation of new QoL assessment tools will have a central role in the advancement of therapies and treatment guidelines for AF.

Effect of pacing method on risk of sudden death after atrioventricular node ablation and pacemaker implantation in patients with atrial fibrillation

BACKGROUND

Sudden death may occur after radiofrequency catheter ablation of the atrioventricular node (AVN) and permanent pacemaker implantation. It is unclear whether a faster initial heart rate with gradual rate reduction decreases the risk of sudden death.

OBJECTIVE

To evaluate the effects of initial pacing at a faster rate after AVN ablation, with a gradual rate decrease over 3 months, on the rate of sudden death in patients with atrial fibrillation.

METHODS

We compared the rate of likely or possible procedure-related sudden death in 2 groups of patients who had AVN ablation and pacemaker implantation. The study cohort was treated between January 2005 and December 2009, and pacemakers were programmed to a lower rate of 90 beats/min after the procedure, with a monthly decrement of 10 beats/min until 60 beats/min was reached. The control group was treated between July 1990 and December 1998 when pacemakers were programmed to a lower rate of 60 beats/min immediately after ablation.

RESULTS

The study cohort included 520 patients (mean age 73.6 ± 10.3 years), and the control cohort comprised 334 patients (mean age 68.1 ± 1.1 years). Sudden death deemed likely or possibly related to ablation and pacemaker implantation occurred in 1 patient in the study cohort (0.2%) and in 7 patients (2.1%) in the control group (P = .007).

CONCLUSIONS

Sudden death was significantly decreased in the study cohort compared to controls. The faster lower pacing rate immediately after AVN ablation with a gradual decrease is a plausible mechanism for the improved clinical outcome.

Adverse effects of permanent atrial fibrillation on heart failure in patients with preserved left ventricular function and chronic right apical pacing for complete heart block

BACKGROUND

The impact of atrial fibrillation (AF) on heart failure (HF) was evaluated in patients with preserved left ventricular (LV) function and long-term right ventricular (RV) pacing for complete heart block.

METHODS

Clinical, echocardiographic, and laboratory parameters of HF were assessed in 35 patients with established AF who had undergone ablation of the atrioventricular node and pacemaker implantation (Group A) and 31 patients who received dual-chamber pacing for spontaneous complete heart block (Group B).

RESULTS

During a follow-up period of 12.7 ± 7.5 years, New York Heart Association (NYHA) functional class increased from 1.3 ± 0.5 to 2.1 ± 0.6 (p < 0.0001) in Group A, and from 1.3 ± 0.4 to 1.6 ± 0.7 (p < 0.01) in Group B. Left ventricular ejection fraction (LVEF) decreased from 59.7 ± 5.1 to 53.0 ± 8.2 (p < 0.0001) in Group A, but remained stable (58.6 ± 4.2 vs. 56.9 ± 7.0 %, p = 0,21) in Group B. At the end of follow-up, markers of LV function were moderately depressed in Group A compared with those in Group B: NYHA class 2.1 ± 0.6 versus 1.6 ± 0.7, p = 0.001; LVEF 53.0 ± 8.2 versus 56.9 ± 7.0 %, p < 0.05; LV diastolic diameter 53.6 ± 5.8 mm versus 50.7 ± 4.9 mm, p < 0.05; N-terminal pro-brain natriuretic peptide (NT-proBNP) 1116.8 ± 883.9 versus 622.9 ± 1059.4 pg/ml, p < 0.05. Progression of paroxysmal AF to permanent AF during follow-up was common, while new onset of AF was rare. Permanent AF was an independent predictor of declining LVEF >10 %, increasing NYHA class ≥1, and NT-proBNP levels >1,000 pg/ml.

CONCLUSIONS

Permanent AF was associated with adverse effects on LV function and symptoms of HF in patients with long-term RV pacing for complete heart block, and appears to play an important role in the development of HF in this specific patient cohort.

Atrioventricular nodal ablation versus antiarrhythmic drugs after permanent pacemaker implantation for bradycardia-tachycardia syndrome

Patients often require antiarrhythmic drugs to control tachycardia after permanent pacemaker implantation (PMI) for bradycardia-tachycardia syndrome. We compared atrioventricular nodal ablation (AVNA) to antiarrhythmic drugs after PMI for bradycardia-tachycardia syndrome. Twenty-eight symptomatic patients with bradycardia-tachycardia syndrome, all of which had a long pause after termination of paroxysmal atrial fibrillation, underwent PMI with RV lead placement at the mid-septum site. Among these patients, 14 underwent PMI and AVNA (AVNA group). The remaining 14 patients underwent PMI only, and continued to take anti-arrhythmic drugs (drug group). We compared cardiac function (cardio-thoracic ratio on chest X-ray, left atrial diameter, left ventricular end-diastolic dimension, and left ventricular-ejection fraction by echocardiography), exercise tolerance (6-min walking distance), symptoms, and the number of antiarrhythmic drugs just before and 6 months after PMI. Baseline characteristics were similar between the two groups, except for the number of antiarrhythmic drugs. Six months after PMI, cardiac function, exercise tolerance, and symptoms did not differ significantly between the two groups. Compared to the drug group (p < 0.01), the number of antiarrhythmic drugs was significantly smaller in the AVNA group 6 months after PMI. Patients who underwent AVNA concurrently with PMI with RV lead placement at the mid-septum site for bradycardia-tachycardia syndrome were able to reduce the intake of drugs and improve their tachycardia-related symptoms while maintaining cardiac function and exercise tolerance.

Quality of life in patients with atrial fibrillation: a systematic review

The impact of atrial fibrillation (AF) on patients' quality of life (QoL) has yet to be fully elucidated in a systematic manner. This article examines QoL in "general" patients with AF as well as the effects that rate and/or rhythm-control interventions have on QoL. Patients with AF have significantly poorer QoL compared with healthy controls, the general population, and other patients with coronary heart disease. Studies examining rate or rhythm-control strategies alone demonstrate improved QoL after intervention. Three of the four large randomized control trials (STAF, PIAF, RACE) comparing rate versus rhythm control demonstrated a greater improvement in QoL in patients receiving rate control. However, the AFFIRM trial revealed a similar improvement in QoL for both rate and rhythm-control groups. The data, although frequently compromised by various methodologic weaknesses, suggest that patients with AF have impaired QoL, and that QoL can be significantly improved through rate or rhythm-control strategies.