Tachycardia-Induced Cardiomyopathy: A Review of Literature

Adolescent Onset of Acute Heart Failure

Heart failure in adolescents can manifest due to a multitude of causes. Presentation is often quite variable ranging from asymptomatic to decompensated heart failure or sudden cardiac death. Because of the diverse nature of this disease, a thoughtful and extensive evaluation is critical to establishing the diagnosis and treatment plan. Identifying and addressing reversible pathologies often leads to functional cardiac recovery. Some disease states are irreversible and progressive, requiring chronic heart failure management and potentially advanced therapies such as transplantation.

An Updated Review on the Role of Non-dihydropyridine Calcium Channel Blockers and Beta-blockers in Atrial Fibrillation and Acute Decompensated Heart Failure: Evidence and Gaps

PURPOSE

The 2021 European Society of Cardiology guidelines on acute and chronic heart failure (HF) recommend that non-dihydropyridine calcium channel blockers (NDCC) should be avoided in patients with HF with reduced ejection fraction. It also emphasizes that beta-blockers only be initiated in clinically stable, euvolemic patients. Despite these recommendations, NDCC and beta-blockers are often still employed in patients with AF with rapid ventricular response and acute decompensated HF. The relative safety and efficacy of these therapies in this setting is unclear.

METHODS

To address the question of the safety and efficacy of NDCC and beta-blockers for acute rate control in decompensated HF, we provide a perspective on the literature of NDCC and beta-blockers in chronic HF with reduced and preserved ejection fraction and AF, including trials on the management of AF with rapid ventricular response with and without HF.

RESULTS

Robust data demonstrates mortality benefits when beta-blockers are used in patients with chronic HF with reduced ejection fraction. The data that inform the contraindication of NDCC in HF with reduced ejection fraction are outdated and were not primarily designed to address the efficacy and safety of rate control of AF in patients with HF. Several studies indicate that for acute rate control, NDCC and beta-blockers are both efficacious therapies, especially in the setting of tachycardia-induced cardiomyopathy.

CONCLUSION

Future studies are needed to assess the safety and efficacy of beta-blockers and NDCC in both acute and chronic AF with HF with reduced and preserved ejection fraction.

Emerging concepts in heart failure management and treatment: focus on tachycardia-induced cardiomyopathy

Tachycardia-induced cardiomyopathy is an entity characterized by reversible dysfunction of the left ventricle, which can be induced by different types of arrhythmia such as atrial fibrillation, atrial flutter, incessant supraventricular tachycardia and ventricular arrhythmia (more frequent causes). Correct identification of the causative arrhythmia and normalization of the heart rate (e.g through medical treatment, electrical cardioversion, ablation) can lead to recovery of left ventricular function. Tachycardia-induced cardiomyopathy should be suspected in patients with tachycardia and left ventricular dysfunction (heart failure setting), especially when there is no history of previous heart disease. Its usual phenotype is that of non-ischaemic/non-valvular dilated cardiomyopathy and it can occur in both children (main cause: permanent junctional reciprocating tachycardia) and adults (main cause: atrial fibrillation). With proper treatment, most cases recover within a few months, though there is a risk of relapse, especially when the causal arrhythmia reappears or its control is lost. This is a narrative review that comprehensively addresses the pathophysiology, clinical manifestations, and therapeutic management of tachycardia-induced cardiomyopathy. This article is part of the Emerging concepts in heart failure management and treatment Special Issue: https://www.drugsincontext.com/special_issues/emerging-concepts-in-heart-failure-management-and-treatment.

Loss-of-function mutations in the co-chaperone protein BAG5 cause dilated cardiomyopathy requiring heart transplantation

Dilated cardiomyopathy (DCM) is a major cause of heart failure, characterized by ventricular dilatation and systolic dysfunction. Familial DCM is reportedly caused by mutations in more than 50 genes, requiring precise disease stratification based on genetic information. However, the underlying genetic causes of 60 to 80% of familial DCM cases remain unknown. Here, we identified that homozygous truncating mutations in the gene encoding Bcl-2-associated athanogene (BAG) co-chaperone 5 (BAG5) caused inherited DCM in five patients among four unrelated families with complete penetrance. BAG5 acts as a nucleotide exchange factor for heat shock cognate 71 kDa protein (HSC70), promoting adenosine diphosphate release and activating HSC70-mediated protein folding. Bag5 mutant knock-in mice exhibited ventricular dilatation, arrhythmogenicity, and poor prognosis under catecholamine stimulation, recapitulating the human DCM phenotype, and administration of an adeno-associated virus 9 vector carrying the wild-type BAG5 gene could fully ameliorate these DCM phenotypes. Immunocytochemical analysis revealed that BAG5 localized to junctional membrane complexes (JMCs), critical microdomains for calcium handling. Bag5-mutant mouse cardiomyocytes exhibited decreased abundance of functional JMC proteins under catecholamine stimulation, disrupted JMC structure, and calcium handling abnormalities. We also identified heterozygous truncating mutations in three patients with tachycardia-induced cardiomyopathy, a reversible DCM subtype associated with abnormal calcium homeostasis. Our study suggests that loss-of-function mutations in BAG5 can cause DCM, that BAG5 may be a target for genetic testing in cases of DCM, and that gene therapy may potentially be a treatment for this disease.

Effect of landiolol in patients with tachyarrhythmias and acute decompensated heart failure (ADHF): a case series

Tachycardia and rapid tachyarrhythmias are common in acute clinical settings and may hasten the deterioration of haemodynamics in patients with acute decompensated heart failure (ADHF), treated with inotropes. The concomitant use of a short‐acting β1‐selective beta‐blocker, such as landiolol, could rapidly and safely restore an adequate heart rate without any negative inotropic effect. We present a case series of five patients with left ventricular dysfunction, admitted to our Intensive Cardiac Care Unit with ADHF deteriorated to cardiogenic shock, treated with a combination of landiolol and inotropes. Landiolol was effective in terms of rate control and haemodynamics optimization, enabling de‐escalation of catecholamine dosing in all patients. The infusion was always well tolerated without hypotension. In conclusion, a continuous infusion of a low dose of landiolol (3–16 mcg/kg/min) to manage tachycardia and ventricular or supraventricular tachyarrhythmias in haemodynamically unstable patients may be considered.

A Novel Gene Signature to Predict Survival Time and Incident Ventricular Arrhythmias in Patients with Dilated Cardiomyopathy

The mortality in nonischaemic dilated cardiomyopathy (NIDCM) patients is still at a high level; sudden death in NIDCM can be caused by ventricular tachycardia. It is necessary to explore the pathogenesis of ventricular arrhythmias (VA) in NIDCM. Differentially expressed genes (DEGs) were identified by comparing the gene expression of NIDCM patients with or without VA in the gene expression profile of GSE135055. A total of 228 DEGs were obtained, and 3 genes were screened out to be significantly related to the survival time of NIDCM patients. We established a prediction model on two-gene (TOMM22, PPP2R5A) signature for the survival time of NIDCM patients. The area under the curve (AUC) was 0.75 calculated by the ROC curve analysis. These risk genes are probably new targets for exploring the pathogenesis of NIDCM with VA; the prediction model for survival time and incident ventricular arrhythmias is useful in clinical decision making for individual treatment.

Atrial fibrillation in patients with systolic heart failure: pathophysiology mechanisms and management

Heart failure (HF) and atrial fibrillation (AF) demonstrate a constantly increasing prevalence during the 21^st century worldwide, as a result of the aging population and the successful interventions of the clinical practice in the deterioration of adverse cardiovascular outcomes. HF and AF share common risk factors and pathophysiological mechanisms, creating the base of a constant interrelation. AF impairs systolic and diastolic function, resulting in the increasing incidence of HF, whereas the structural and neurohormonal changes in HF with preserved or reduced ejection fraction increase the possibility of the AF development. The temporal relationship of the development of either condition affects the diagnostic algorithms, the prognosis and the ideal therapeutic strategy that leads to euvolaemia, management of non-cardiovascular comorbidities, control of heart rate or restoration of sinus rate, ventricular synchronization, prevention of sudden death, stroke, embolism, or major bleeding and maintenance of a sustainable quality of life. The indicated treatment for the concomitant HF and AF includes rate or/and rhythm control as well as thromboembolism prophylaxis, while the progress in the understanding of their pathophysiological interdependence and the introduction of the genetic profiling, create new paths in the diagnosis, the prognosis and the prevention of these diseases.

Invasive therapies for patients with concomitant heart failure and atrial fibrillation

Atrial fibrillation (AF) and heart failure (HF) are two clinical entities that can present either separately or concurrently. One entity can lead to the other and vice versa as AF can not only be the underlying etiology of HF but also exacerbate HF due to other cardiac diseases. Besides prevention of cerebral and systemic embolism and elimination of AF-related symptoms, restoration of sinus rhythm for AF patients helps to avoid or reduce HF, irrespective of their underlying heart disease. Successful rates of medical therapy for AF are low in persistent AF, and much lower in long-standing AF, while invasive procedures for AF yield promising results. In this review, the authors evaluate the value of invasive therapies for HF patients complicated with non-valvular AF. We examine this clinical problem by interpreting the relationships between these two entities: the mechanism of tachycardia-induced cardiomyopathy (TIC), past opinions about rhythm control and rate control of AF, discrimination of HF-related AF and AF-induced HF, how to identify the AF patients that could benefit from invasive therapies, and how to select invasive therapies for different AF patients and peri-operative treatments.

Tachycardia induced Cardiomyopathy

Recent studies on radiofrequency catheter ablation (RFCA) in atrial fibrillation show its effectiveness in heart failure (HF) patients; hence, tachycardia-induced cardiomyopathy (T-CMP) is gaining attention. Tachycardia-mediated cardiomyopathy is a reversible left ventricular (LV) dysfunction, which can be induced by any tachyarrhythmia. Early recognition of T-CMP with appropriate treatment of the arrhythmia culprit will lead to the recovery of LV function. Patients with tachycardia and LV dysfunction should be suspected of having T-CMP, with or without established etiology of HF, because T-CMP may present by itself or contribute as a co-existent component. Therapeutic options include rate control, anti-arrhythmic drugs, or catheter ablation. Unlike in animal models, clinical data on human T-CMP is limited. Hence, future research should be more focused on tachyarrhythmia-induced cardiomyopathy as its burden is increasing.

KSHF Guidelines for the Management of Acute Heart Failure: Part III. Specific Management of Acute Heart Failure According to the Etiology and Co-morbidity

The prevalence of heart failure (HF) is on the rise due to the aging of society. Furthermore, the continuous progress and widespread adoption of screening and diagnostic strategies have led to an increase in the detection rate of HF, effectively increasing the number of patients requiring monitoring and treatment. Because HF is associated with substantial rates of mortality and morbidity, as well as high socioeconomic burden, there is an increasing need for developing specific guidelines for HF management. The Korean guidelines for the diagnosis and management of chronic heart failure (CHF) were introduced in March 2016. However, CHF and acute heart failure (AHF) represent distinct disease entities. Here, we introduce the Korean guidelines for the management of AHF with reduced or preserved ejection fraction. Part III of this guideline covers management strategies optimized according to the etiology of AHF and the presence of co-morbidities.

Predictors of reversible severe functional tricuspid regurgitation in patients with atrial fibrillation

BACKGROUND

Atrial remodeling associated with atrial fibrillation (AF) is known to be a risk factor for significant tricuspid regurgitation (TR), but the predictor of reversible TR in patients with severe functional TR and AF has been poorly studied. The aim of this study was to investigate the predictors of reversible TR in patients with severe functional TR and AF.

METHODS

Among 232 patients with severe TR, a total of 71 patients with severe functional TR and AF were enrolled and divided into 2 groups: reversible TR group (n=16, 70.1±15.5 years, 7 males) vs. non-reversible TR group (n=55, 72.3±11.8 years, 20 males). Improvement of TR to moderate or lesser degree on follow-up (FU) echocardiography was considered as reversible TR in the present study.

RESULTS

During 38.9±26.7 months of FU period, reversible TR was observed in 16 patients (22.5%). The presence of left ventricular (LV) systolic dysfunction was significantly prevalent (43.8% vs. 20.0%, p=0.03) and the improvement in LV ejection fraction (EF) more than 10% on FU echocardiography was more significantly frequent (62.5% vs. 23.3%, p=0.003) in the reversible TR group than in the non-reversible TR group. However, the other echocardiographic parameters, including right ventricular function were not different between the groups. In multivariate analysis using Cox proportional hazard model, the improvement of LVEF more than 10% was the only independent predictor of reversible TR (HR=7.39, 95%CI 1.80-30.28, p=0.005). Nine patients died only in patients with non-reversible TR (12.7%), but the reversibility of TR was not associated with mortality.

CONCLUSIONS

The improvement of LV systolic function was the only independent predictor of reversible TR. Appropriate medical therapy including management for heart failure should be considered before performing surgery in patients with severe functional TR and AF, especially in patients with LV dysfunction.

What About Tachycardia-induced Cardiomyopathy?

Long-standing tachycardia is a well-recognised cause of heart failure and left ventricular dysfunction, and has led to the nomenclature, tachycardia-induced cardiomyopathy (TIC). TIC is generally a reversible cardiomyopathy if the causative tachycardia can be treated effectively, either with medications, surgery or catheter ablation. The diagnosis is usually made after demonstrating recovery of left ventricular function with normalisation of heart rate in the absence of other identifiable aetiologies. One hundred years after the first reported case of TIC, our understanding of the pathophysiology of TIC in humans remains limited despite extensive work in animal models of TIC. In this review we will discuss the proposed mechanisms of TIC, the causative tachyarrhythmias and their treatment, outcomes for patients diagnosed with TIC, and future directions for research and clinical care.

Novel perspectives on arrhythmia-induced cardiomyopathy: pathophysiology, clinical manifestations and an update on invasive management strategies

Arrhythmia-induced cardiomyopathy is a partially or completely reversible form of myocardial dysfunction due to sustained supraventricular and ventricular arrhythmias. Asynchrony, rapid cardiac rates and rhythm irregularities are the main factors involved in the development of the disease. The reversible nature of arrhythmia-induced cardiac dysfunction allows only for a retrospective diagnosis of the disease once cardiac function is restored following heart rate control. A high level of suspicion is needed to make a diagnosis at an early stage and prevent further progression of the disease. Although reversible, arrhythmia-induced cellular and molecular changes may remain, increasing the risk for sudden death even when normal ejection fraction is restored as well as causing rapid deterioration of cardiac function and development of heart failure symptoms if arrhythmia recurs. Appropriate management based on a combination of pharmacologic and nonpharmacologic strategies to achieve rate control and prevent arrhythmia recurrence is pivotal to avoid further cardiac function deterioration and to control symptoms, significantly reducing the risk of heart failure and sudden cardiac death.

Practical applicability of landiolol, an ultra-short-acting β1-selective blocker, for rapid atrial and ventricular tachyarrhythmias with left ventricular dysfunction

Background

Landiolol effectively controls rapid heart rate in atrial fibrillation or flutter (AF/AFL) patients with left ventricular (LV) dysfunction. However, predicting landiolol Responders and Non-Responders and patients who will experience adverse effects remains a challenge. The aim of this study was to clarify the potential applicability of landiolol for rapid AF/AFL and refractory ventricular tachyarrhythmias (VTs) in patients with heart failure.

Methods

A total of 39 patients with AF/AFL with ventricular response ≥120 bpm and 12 VTs were retrospectively enrolled. Landiolol Responders for rapid AF/AFL were defined as patients whose ventricular response was suppressed to less than 110 bpm or decreased by ≥20% from the initial heart rate after administration of landiolol. Responders for VTs were defined as patients with no recurrent VTs during the 24 h after the initiation of landiolol.

Results

For AF/AFL, 29 patients (74%) were Responders. In nine patients (31%), AF was spontaneously terminated after starting landiolol. Eight Non-Responders (80%) needed to have AF terminated by cardioversion. Left ventricular ejection fraction (LVEF) at baseline was significantly associated with landiolol efficacy. For VTs, seven patients (58%) were Responders, and smaller LV diastolic and systolic diameters were associated with landiolol efficacy. Hypotension after landiolol treatment occurred in 5 of 51 patients, and lower LV systolic function was associated with the development of adverse events.

Conclusions

Landiolol is effective in patients with heart failure not only due to rapid AF/AFL but also due to VTs. However, preserved LVEF is important for efficacy and safety in landiolol treatment.

Progressive development of cardiomyopathy following altered autonomic activity in status epilepticus

Seizures are associated with altered autonomic activity, which has been implicated in the development of cardiac dysfunction and structural damage. This study aimed to investigate the involvement of the autonomic nervous system in seizure-induced cardiomyopathy. Male Sprague-Dawley rats (320–350 g) were implanted with EEG/ECG electrodes to allow simultaneous telemetric recordings during seizures induced by intrahippocampal (2 nmol, 1 μl/min) kainic acid and monitored for 7 days. Seizure activity occurred in conjunction with increased heart rate (20%), blood pressure (25%), and QTc prolongation (15%). This increased sympathetic activity was confirmed by the presence of raised plasma noradrenaline levels at 3 h post-seizure induction. By 48 h post-seizure induction, sympathovagal balance was shifted in favor of sympathetic dominance, as indicated by both heart rate variability (LF/HF ratio of 3.5 ± 1.0) and pharmacological autonomic blockade. Functional cardiac deficits were evident at 7 and 28 days, as demonstrated by echocardiography showing a decreased ejection fraction (14% compared with control, P < 0.05) and dilated cardiomyopathy present at 28 days following seizure induction. Histological changes, including cardiomyocyte vacuolization, cardiac fibrosis, and inflammatory cell infiltration, were evident within 48 h of seizure induction and remained present for up to 28 days. These structural changes most probably contributed to an increased susceptibility to aconitine-induced arrhythmias. This study confirms that prolonged seizure activity results in acute and chronic alterations in cardiovascular control, leading to a deterioration in cardiac structure and function. This study further supports the need for modulation of sympathetic activity as a promising therapeutic approach in seizure-induced cardiomyopathy.

Optimal noninvasive assessment of initial left ventricular dysfunction in children with ectopic atrial tachycardia

Tissue Doppler imaging (TDI) can identify cardiac dysfunction in adults. This study is aimed to improve early identification of initial left ventricular (LV) dysfunction secondary to ectopic atrial tachycardia (EAT) in children by TDI. A total of 70 children with EAT were included in the present study. Cardiac function was evaluated by conventional echocardiography, TDI, and plasma N-terminal pro-brain natriuretic peptide (NT-proBNP). Doppler signals obtained from the mitral inflow and TDI of the mitral annulus were the average values of three consecutive heartbeats. Left ventricular ejection fraction (LVEF), peak early diastolic transmitral velocity (E), peak systolic mitral annulus velocity (S'), early diastolic mitral annular velocity (E'), the ratio E/E', and TDI-derived myocardial performance index (TDI-MPI) were compared between two groups of children with normal or elevated plasma NT-proBNP concentrations. Of the children, 18.6% demonstrated tachycardia-induced cardiomyopathy (TIC). Compared with LVEF, the TDI-MPI and E/E' showed better correlations with elevated plasma NT-proBNP. Addition of TDI-MPI and E/E' to LVEF provided increased information to detect elevated plasma NT-proBNP (91.67% sensitivity).

CONCLUSIONS

TIC occurred in 18.6% of children with EAT. Initial LV dysfunction assessed by the TDI-MPI and E/E' is associated with elevated plasma NT-proBNP, even the LVEF is normal.

Relationship of resting heart rate and physical activity with insulin sensitivity in a population-based survey

BACKGROUND

Resting heart rate (RHR) has been identified as an independent risk factor for cardiovascular disease and mortality, contributing to atherosclerosis, the progression of heart failure, and myocardial ischemia and infarction. This study examines the association RHR and physical activity has with insulin resistance and insulin secretion in a multiethnic cohort from North Kohala, Hawai'i.

METHODS

Cross-sectional data from 1,440 participants of Native Hawaiian, Japanese, Filipino, Caucasian, and mixed ethnic ancestries were analyzed for the study to include anthropometric measurements, and biochemical markers. Body fat was estimated by calculating body mass indices (BMI); body fat distribution by waist-hip ratios (WHR); and fasting plasma glucose and insulin levels were used to calculate insulin resistance using the Homeostasis Model (HOMA-IR). First phase insulin response was estimated using the insulin secretion ratio (ISR). Associations were estimated using general linear models (GLM).

RESULTS

Caucasians had lower mean RHR than all other ethnic groups; there were no statistically significant differences between other ethnic groups on mean RHR. HOMA-IR was associated with ethnic group, BMI and WHR, PA and RHR, while ISR was associated with age, ethnic group and BMI, but none of the primary risk factors. Both RHR and physical activity level remained significant for insulin resistance.

CONCLUSIONS

In a multiethnic cohort from a rural community in Hawai'i, increased RHR and a lower level of physical activity were both independently associated with increased risk for the development of insulin resistance, suggesting cardiovascular fitness may be as important as physical activity in preventing insulin resistance.

Prediction of left ventricular reverse remodeling after therapy with angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers and β blockers in patients with idiopathic dilated cardiomyopathy

Background

Predictors of left ventricular reverse remodeling (LVRR) after therapy with angiotensin converting enzyme inhibitors or angiotensin-receptor blockers and β blockers in patients with idiopathic dilated cardiomyopathy (IDC) remains unclear.

Methods

We studied 44 patients with IDC who had been treated with the therapy. LVRR was defined as LV end-diastolic dimension ≤ 55 mm and fractional shortening ≥ 25% at the last echocardiogram.

Results

During a mean follow-up period of 4.7 ± 3.3 years, LVRR occurred in 34% (15/44) of the patients. We divided the patients into 2 groups: (1) patients with LVRR (n = 15); (2) patients without LVRR (n = 29). The presence of atrial fibrillation was 40% in patients with LVRR and 14% in those without (p = 0.067). Initial LV end-diastolic dimension was significantly smaller (62 ± 6 vs. 67 ± 6 mm, p = 0.033) in patients with LVRR than in those without. Initial LV end-diastolic dimension of 63.5 mm was an optimal cutoff value for predicting LVRR (sensitivity: 67%, specificity: 59%, area under the curve: 0.70, p = 0.030). When patients were further allocated according to initial LV end-diastolic dimension ≤ 63.5 mm with atrial fibrillation, the combined parameter was a significant predictor of LVRR by univariate logistic regression analysis (odds ratio, 5.78, p = 0.030) (sensitivity: 33%, specificity: 97%, p = 0.013).

Conclusions

Combined information on LV end-diastolic dimension and heart rhythm at diagnosis is useful in predicting future LVRR in patients with IDC.

Management of ACCF/AHA Stage A and B patients

Heart failure remains a major health problem in the United States, affecting 5.8 million Americans. Its prevalence continues to rise due to the improved survival of patients. Despite advances in treatment, morbidity and mortality remain very high, with a median survival of about 5 years after the first clinical symptoms. This article describes the causes, classification, and management goals of heart failure in Stages A and B.

Epidemiology and natural history of recovery of left ventricular function in recent onset dilated cardiomyopathies

Although the long term prognosis of patients with dilated cardiomyopathy (DCM) remains poor, approximately 25 % of DCM patients with recent onset of heart failure (< 6 months) have a relatively benign clinical course with a spontaneously improvement in symptoms and partial, or in some cases complete, recovery of left ventricular (LV) function. Despite the longstanding recognition of the clinical phenomenon of LV recovery, relatively little attention has been paid to the etiology and natural history of this important group of DCM patients. Accordingly, in the present review we will focus on the epidemiology and natural history of recent onset DCM in patients who undergo spontaneous resolution of symptoms that is accompanied by recovery of LV function.

Incomplete cure of tachycardia-induced cardiomyopathy secondary to rapid atrial fibrillation by heart rate control without sinus conversion

BACKGROUND

It is uncertain whether rate or rhythm control is more favorable for patients experiencing tachycardia-induced cardiomyopathy (TIC) secondary to rapid atrial fibrillation (AF).

METHODS AND RESULTS

We compared the electrophysiological and hemodynamic properties and outcome after AF ablation in 20 patients with a history of decompensated TIC who maintained sinus rhythm or had paroxysmal AF (group 1), 32 with a history of decompensated TIC who had persistent or longstanding persistent AF (group 2), 377 without TIC who had paroxysmal AF (group 3), and 225 without TIC who had persistent or longstanding persistent AF (group 4). The corrected sinus node recovery time was more prolonged in group 2 than in groups 1, 3, or 4 (1,066 ± 946 vs. 416 ± 188, 450 ± 322 and 590 ± 329 milliseconds; P < 0.001, respectively). The mean left atrial pressure in group 2 was greater than that in groups 1, 3, or 4 (13.9 ± 6.5 vs. 7.5 ± 3.1, 8.2 ± 4.1 and 10.8 ± 4.2 mmHg; P < 0.001, respectively). The left ventricular ejection fraction assessed after the recovery from the decompensation was more decreased in group 2 than in group 1; however, it almost returned to normal if sinus rhythm was maintained after the AF ablation in group 2. The presence of a history of TIC did not predict an AF recurrence after the ablation.

CONCLUSIONS

Heart rate control during AF without sinus conversion may result in an incomplete cure of TIC, suggesting the advantages of rhythm control with ablation in patients with TIC.