Mortality After Atrioventricular Nodal Radiofrequency Catheter Ablation With Permanent Ventricular Pacing in Atrial Fibrillation

Pulmonary Vein Isolation in Elderly Patients ≥ 75 Years: A Propensity Score-Matched Analysis With Focus on Differences Among Atrial Fibrillation Types

BACKGROUND

Age is a major risk factor for development of atrial fibrillation (AF) and associated with increased recurrence rates in the setting of rhythm control. Current data tend to support catheter ablation in elderly patients, but uncertainties exist regarding efficacy and safety of ablation in elderly patients.

METHODS

This was a prospective single-centre observational study with propensity score matching (PSM) to investigate the influence of age on efficacy and safety of cryoballoon ablation (CBA) stratified by age (< 75 years vs ≥ 75 years) and AF phenotype (paroxysmal vs persistent). Primary efficacy endpoint was recurrence of atrial arrhythmia after a 90-day blanking period. Safety endpoints were death, stroke, or procedure-associated complications.

RESULTS

Consecutive patients (n = 953) underwent CBA for first-time AF ablation. Median follow-up was 18 months. By means of PSM, 268 matches were formed. At 1 year, primary efficacy endpoint occurred in 22.4% of young vs 33.2% of elderly patients, including both AF phenotypes (hazard ratio [HR], 0.65; 95% confidence interval [CI], 0.47-0.90; P = 0.01). AF relapse occurred in 19.7% of young vs 28.5% of elderly patients with paroxysmal (HR, 0.63; 95% CI, 0.40-0.99; P = 0.046) compared with 25.9% (30 of 116, young) vs 38.8% (45 of 116, elderly) patients with persistent AF (HR, 0.62; 95% CI, 0.39-0.97; P = 0.038). No difference was observed regarding the incidence of safety endpoints between young and elderly patients (P = 0.38).

CONCLUSIONS

CBA is associated with higher recurrence rates in elderly (≥ 75 years) than in younger patients, with highest recurrence rates in elderly patients with persistent AF.

Importance of resting heart rate

Resting heart rate is a determinant of cardiac output and physiological homeostasis. Although a simple, but critical, parameter, this vital sign predicts adverse outcomes, including mortality, and development of diseases in otherwise normal and healthy individuals. Temporal changes in heart rate can have valuable predictive capabilities. Heart rate can reflect disease severity in patients with various medical conditions. While heart rate represents a compilation of physiological inputs, including sympathetic and parasympathetic tone, aside from the underlying intrinsic sinus rate, how resting heart rate affects outcomes is uncertain. Mechanisms relating resting heart rate to outcomes may be disease-dependent but why resting heart rate in otherwise healthy, normal individuals affects outcomes remains obscure. For specific conditions, physiologically appropriate heart rate reductions may improve outcomes. However, to date, in the normal population, evidence that interventions aimed at reducing heart rate improves outcomes remains undefined. Emerging data suggest that reduction in heart rate via vagal activation and/or sympathetic inhibition is propitious.

A conversion CRT strategy combined with AVJA may be a perspective alternative for heart failure patients with persistent atrial fibrillation

Heart failure (HF) combined with persistent atrial fibrillation (AF) often coexist and may promote the pathological conditions of cardiac dysfunction, leading to poor prognosis. Cardiac resynchronization therapy (CRT) combined with atrioventricular junction ablation (AVJA) is a highly effective treatment for HF patients with underlying AF who either have failed or are not suitable for catheter ablation. The CRT-AVJA combination therapy can improve clinical outcomes in HF patients. Currently, clinical CRT methods are categorized into biventricular pacing (BVP) - based and conduction system pacing (CSP) - based methods. These procedures have inherent advantages and disadvantages, in addition to their considerable differences in clinical applications. This article aims to review the clinical progress of AVJA combined with different CRT strategies for treating HF patients with persistent AF and propose that conversion CRT strategy (BVP/CSP-CRT) combined with AVJA may be a perspective alternative. Meanwhile, we generalize that 7 categories of HF patients with persistent AF may need to consider the CRT-AVJA combination therapy.

His-bundle pacing and atrioventricular nodal ablation for noncontrolled atrial arrhythmia: A technical challenge with major clinical benefits

BACKGROUND

His-bundle pacing (HBP) is an appealing alternative to right ventricular pacing in patients referred for permanent ventricular pacing and atrioventricular nodal ablation (AVNA) because it preserves physiological ventricular activation. Only limited data regarding HBP combined with AVNA are available in the literature.

OBJECTIVE

The purpose of this study was to provide further evidence on the feasibility and efficacy of this therapeutic approach in patients with uncontrolled atrial arrhythmia.

METHODS

We prospectively included all patients who had undergone AVNA after HBP in 3 different hospitals between 2017 and 2022.

RESULTS

AVNA following HBP lead implantation was performed in 75 patients. Complete atrioventricular (AV) block was obtained in 58 patients (77%), and significant modulation of AV nodal conduction (heart rate <60 bpm) was obtained in 12 patients (16%). AVNA failure was observed in 5 patients (7%). Recording of an atrial signal by the HBP lead was more frequently observed in patients with AVNA modulation/failure than in patients with complete AV block (11/17 vs 5/58; P <.001). No lead dislodgment occurred during the AVNA procedures. Acute His-bundle (HB) capture threshold increase >1 V occurred in 11 patients (15%), with return to baseline value on day 1 in 9 patients. New York Heart Association functional class and left ventricular ejection fraction significantly improved from baseline to last follow-up (3.0 ± 0.7 vs 1.6 ± 0.5; P <.001; and 47% ± 14% vs 60% ± 9%; P <.0001, respectively).

CONCLUSION

AVNA combined with HBP for noncontrolled atrial arrhythmia was feasible and clinically efficient. Implanting the HB lead on the ventricular aspect of the tricuspid annulus avoiding atrial signal recording can facilitate AVNA.

AV junction ablation and cardiac resynchronization for patients with permanent atrial fibrillation and narrow QRS: the APAF-CRT mortality trial

AIMS 

In patients with atrial fibrillation (AF) and heart failure (HF), strict and regular rate control with atrioventricular junction ablation and biventricular pacemaker (Ablation + CRT) has been shown to be superior to pharmacological rate control in reducing HF hospitalizations. However, whether it also improves survival is unknown.

METHODS AND RESULTS 

In this international, open-label, blinded outcome trial, we randomly assigned patients with severely symptomatic permanent AF >6 months, narrow QRS (≤110 ms) and at least one HF hospitalization in the previous year to Ablation + CRT or to pharmacological rate control. We hypothesized that Ablation + CRT is superior in reducing the primary endpoint of all-cause mortality. A total of 133 patients were randomized. The mean age was 73 ± 10 years, and 62 (47%) were females. The trial was stopped for efficacy at interim analysis after a median of 29 months of follow-up per patient. The primary endpoint occurred in 7 patients (11%) in the Ablation + CRT arm and in 20 patients (29%) in the Drug arm [hazard ratio (HR) 0.26, 95% confidence interval (CI) 0.10-0.65; P = 0.004]. The estimated death rates at 2 years were 5% and 21%, respectively; at 4 years, 14% and 41%. The benefit of Ablation + CRT of all-cause mortality was similar in patients with ejection fraction (EF) ≤35% and in those with >35%. The secondary endpoint combining all-cause mortality or HF hospitalization was significantly lower in the Ablation + CRT arm [18 (29%) vs. 36 (51%); HR 0.40, 95% CI 0.22-0.73; P = 0.002].

CONCLUSIONS 

Ablation + CRT was superior to pharmacological therapy in reducing mortality in patients with permanent AF and narrow QRS who were hospitalized for HF, irrespective of their baseline EF.

STUDY REGISTRATION

ClinicalTrials.gov Identifier: NCT02137187.

Effectiveness and safety of AV node ablation after His bundle pacing in patients with uncontrolled atrial arrhythmias

INTRODUCTION

In patients with uncontrolled atrial fibrillation, atrioventricular (AV) node ablation after permanent His bundle pacing (p-HBP) could be a therapeutic option for heart rate (HR) control. We aimed to demonstrate the advantages of AV node ablation with p-HBP, and to describe its effectiveness and safety.

METHODS

This descriptive observational study included patients with uncontrolled permanent atrial arrhythmias who were candidates for HR control (January 2019 to July 2020) and underwent p-HBP and AV node ablation.

RESULTS

A total of 39 patients were included. The median left ventricular ejection fraction (LVEF) was 55% (45-60); 46.1% in NYHA class II and 43.6% in NYHA class III. p-HBP was achieved in 92.3% (n = 36), and AV node ablation was successfully performed in all patients. The LVEF improved in patients with reduced LVEF (baseline, 35% [23.8-45.3%]; follow-up, 40% [35-56.5%], p < 0.05); the NYHA class also showed improvement (baseline, 71.4% patients in class III and 7.1% in class II, and at follow-up, 78.6% patients in class II and 14.3% in class I). In patients with previously normal LVEF, LVEF remained stable; nevertheless, a significant NYHA class improvement was observed (baseline, 63.6% class II and 31.8% class III patients; follow-up, 54.5% class I and 45.5% class II patients). The His thresholds and lead parameter values did not significantly change during the follow-up and remained stable.

CONCLUSIONS

In patients with uncontrolled atrial arrhythmias who underwent AV node ablation after p-HBP, the NYHA class improved and the LVEF increased in those with reduced baseline LVEF. The values of pacing parameters were acceptable and remained stable during the follow-up.

The Benefit of Atrioventricular Junction Ablation for Permanent Atrial Fibrillation and Heart Failure Patients Receiving Cardiac Resynchronization Therapy: An Updated Systematic Review and Meta-analysis

BACKGROUND

Atrial fibrillation (AF) is correlated with a poor biventricular pacing and inadequate response to cardiac resynchronization therapy (CRT). Biventricular pacing improvement can be achieved by conducting the atrioventricular junction ablation (AVJA). We aimed to investigate the benefit of AVJA for permanent AF and heart failure with reduced ejection fraction (HFrEF) patients receiving CRT.

METHODS

In August 2020, a systematic review and meta-analysis study comparing CRT plus AVJA versus CRT for permanent AF and HFrEF patients was conducted. Relevant articles were identified through the electronic scientific database such as ClinicalTrials.gov, ProQuest, ScienceDirect, PubMed, and Cochrane. The pooled risk ratio (RR) and pooled mean difference (MD) were estimated.

RESULTS

A total of 3199 patients from 14 cohort studies were involved in this study. Additional AVJA reduced cardiovascular mortality (RR = 0.75, 95% confidence interval [CI] = 0.61 to 0.93, P < 0.01) in permanent AF and HFrEF patients receiving CRT. Biventricular pacing rate was higher in CRT plus AVJA group (MD = 8.65%, 95% CI = 5.62 to 11.67, P < 0.01) than in CRT alone group. The reverse remodeling characterized by the reduction of left ventricular end-diastolic diameter (LVEDD) was greater in the CRT plus AVJA group (MD = -2.11 mm, 95% CI = -3.79 to -0.42, P = 0.01).

CONCLUSION

In permanent AF and HFrEF patients receiving CRT, AVJA effectively increased the biventricular pacing rate. Adequate biventricular pacing rate provided a better response to the CRT marked by the greater ventricular reverse remodeling and survival from cardiovascular mortality.

Long-term outcomes after radiofrequency catheter ablation of the atrioventricular node: The experience of a Portuguese tertiary center

INTRODUCTION

In patients with supraventricular arrhythmias and high ventricular rate, unresponsive to rate and rhythm control therapy or catheter ablation, atrioventricular (AV) node ablation may be performed.

OBJECTIVES

To assess long-term outcomes after AV node ablation and to analyze predictors of adverse events.

METHODS

We performed a detailed retrospective analysis of all patients who underwent AV node ablation between February 1997 and February 2019, in a single Portuguese tertiary center.

RESULTS

A total of 123 patients, mean age 69±9 years and 52% male, underwent AV node ablation. Most of them presented atrial fibrillation at baseline (65%). During a median follow-up of 8.5 years (interquartile range 3.8-11.8), patients improved heart failure (HF) functional class (NYHA class III-IV 46% versus 13%, p=0.001), and there were reductions in hospitalizations due to HF (0.98±1.3 versus 0.28±0.8, p=0.001) and emergency department (ED) visits (1.1±1 versus 0.17±0.7, p=0.0001). There were no device-related complications. Despite permanent pacemaker stimulation, left ventricular ejection fraction did not worsen (47±13% vs. 47%±12, p=0.63). Twenty-eight patients died (23%). The number of ED visits due to HF before AV node ablation was an independent predictor of the composite adverse outcome (OR 1.8, 95% CI 1.24-2.61, p=0.002).

CONCLUSIONS

Despite pacemaker dependency, the clinical benefit of AV node ablation persisted at long-term follow-up. The number of ED visits due to HF before AV node ablation was an independent predictor of the composite adverse outcome. AV node ablation should probably be considered earlier in the treatment of patients with supraventricular arrhythmias and HF, especially in cases that are unsuitable for selective ablation of the specific arrhythmia.

Acute and long-term outcomes of left-sided atrioventricular node ablation in patients with atrial fibrillation

PURPOSE

To present our experience regarding acute and long-term outcomes of left-sided atrioventricular node (AVN) ablation in patients with atrial fibrillation (AF).

METHODS

A total of 47 patients with AF in whom left-sided AVN ablation via retroaortic approach as a first-line approach were enrolled in this retrospective study. Indications for AVN ablation were high ventricular rate refractory to medical therapy, inappropriate implantable cardioverter defibrillator (ICD) shocks, or loss of cardiac resynchronization therapy (CRT) pacing. Both acute and long-term outcomes were assessed for all participants.

RESULTS

Left-sided AVN ablation was successfully performed in 46/47 (98%) patients without any procedural complication. In the remaining 1 patient (2%), right-sided AVN ablation was performed. No mortality was observed within 30 days of the procedure. Upgrade to CRT was performed in 9 (19%) of the patients. During the median 22.5 months of follow-up, all-cause mortality was 25%. Device interrogations on the last clinical visit revealed complete AV block and intrinsic ventricular rate of < 40 bpm in all patients.

CONCLUSION

Left-sided AVN ablation is a safe and effective procedure without recurrence during long-term follow-up.

Long-term experience of atrioventricular node ablation in patients with refractory atrial arrhythmias

Atrial fibrillation and other atrial tachyarrhythmias are increasing with age and concomitant morbidity. First options in symptomatic patients are drug treatment and catheter ablation. Nevertheless, a considerable number of patients suffer from refractory atrial tachyarrhythmias despite treatment. Atrioventricular node ablation (AVNA) may be helpful in many of these patients. Therefore, we investigated AVNA patients with a long-term follow-up. We enrolled 82 patients with a follow-up longer than 1 year receiving AVNA for drug- and ablation-resistant atrial tachyarrhythmias (AA) in a retrospective manner. Mean follow-up duration was 48 ± 24 months. 50% of the patients initially received AVNA to optimize biventricular pacing in cardiac resynchronization therapy, the other 50% because of refractory symptomatic tachyarrhythmias. Persistent AV block was achieved in every patient. Symptom relief and patient satisfaction were high during follow-up. Due to system upgrades there were 63% of patients with a biventricular system during follow-up. In these patients, left-ventricular ejection fraction (LV-EF) increased by 7% (42-49%) after ablation. AVNA is effective in increasing biventricular pacing as well as for symptom relief in patients with refractory atrial tachyarrhythmias. AVNA should be considered as a valuable option in patients with refractory atrial tachyarrhythmias lacking other treatment options.

Outcomes of cardiac resynchronisation therapy in patients with heart failure with atrial fibrillation: a systematic review and meta-analysis of observational studies

Background

Cardiac resynchronisation therapy (CRT) is beneficial in selected patients with heart failure (HF) in normal sinus rhythm (NSR). We sought to evaluate the impact of CRT with or without atrioventricular junction (AVJ) ablation in patients with HF with concomitant atrial fibrillation (AF).

Methods and results

Literature was searched (inception through 30 August 2017) for observational studies that reported outcomes in patients with HF with CRT and AF that reported all-cause and cardiovascular mortality. Thirty-one studies with 83, 571 patients were included. CRT did not decrease mortality compared with internal cardioverter defibrillator or medical therapy alone in patients with HF and AF with indications for CRT (OR: 0.851, 95% CI 0.616 to 1.176, p=0.328, I2=86.954). CRT-AF patients had significantly higher all-cause and cardiovascular mortality than CRT-NSR patients ([OR: 1.472, 95% CI 1.301 to 1.664, p=0.000] and [OR: 1.857, 95% CI 1.350 to 2.554, p=0.000] respectively). Change in left ventricular ejection fraction was not different between CRT patients with and without AF (p=0.705). AVJ ablation, however, improved all-cause mortality in CRT-AF patients when compared with CRT-AF patients without AVJ ablation (OR: 0.485, 95% CI 0.247 to 0.952, p=0.035). With AVJ ablation, there was no difference in all-cause mortality in CRT-AF patients compared with CRT-NSR patients (OR: 1.245, 95% CI 0.914 to 1.696, p=0.165).

Conclusion

The results of our meta-analysis suggest that AF was associated with decreased CRT benefits in patients with HF. CRT, however, benefits patients with AF with AVJ ablation.

Management of asymptomatic arrhythmias: a European Heart Rhythm Association (EHRA) consensus document, endorsed by the Heart Failure Association (HFA), Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), Cardiac Arrhythmia Society of Southern Africa (CASSA), and Latin America Heart Rhythm Society (LAHRS)

Asymptomatic arrhythmias are frequently encountered in clinical practice. Although studies specifically dedicated to these asymptomatic arrhythmias are lacking, many arrhythmias still require proper diagnostic and prognostic evaluation and treatment to avoid severe consequences, such as stroke or systemic emboli, heart failure, or sudden cardiac death. The present document reviews the evidence, where available, and attempts to reach a consensus, where evidence is insufficient or conflicting.

Clinical scores for outcomes of rhythm control or arrhythmia progression in patients with atrial fibrillation: a systematic review

Patients with atrial fibrillation (AF) are commonly managed with rhythm control strategy, but the natural history of this common arrhythmia leads itself to progression from paroxysmal to persistent or permanent AF, and recurrences are evident despite rhythm control treatments using cardioversion or catheter ablation. Numerous clinical factors have been associated with outcomes of rhythm control or arrhythmia progression in patients with AF. The more common factors have been used to formulate risk stratification scores, to help predict the outcomes of rhythm control treatments or AF progression. This review article provides an overview on the published clinical risk scores related to outcomes of rhythm control strategy or AF progression.