Atrial-fib catheter ablation can improve symptoms, NYHA class in HF patients

December 01, 2004

Bordeaux, France - Some HF patients with atrial fibrillation who achieve and maintain sinus rhythm by catheter ablation will improve in ventricular function and symptom status, often without the use of antiarrhythmic drugs, according to a report in the December 2, 2004 issue of the New England Journal of Medicine[1]. In a small but controlled prospective study, ablation achieved those benefits even in such patients who had adequate rate control before the procedure.

"Patients with adequate rate control and coexisting heart disease, including some with severe congestive heart failure who were being considered for cardiac transplantation, also benefited from ablation," write Dr Li-Fern Hsu (Hôpital Cardiologique du Haut-Lévêque, Bordeaux, France) and colleagues. That finding, according to the group, "demonstrates the additional hemodynamic benefits of the restoration of sinus rhythm as compared with pharmacologic rate control."

 
Patients with adequate rate control and coexisting heart disease, including some with severe congestive heart failure who were being considered for cardiac transplantation, also benefited from ablation.
 

The Bordeaux team followed 58 patients with HF of at least NYHA class 2 and an LVEF <45% with an identical number of non-HF control patients after catheter ablation for drug-resistant atrial fibrillation. Patients in the control group were matched for age, sex, and atrial fib classification. The vast majority of HF patients were on beta blockers and either ACE inhibitors or angiotensin-receptor blockers.

The results

After a mean of one year, 78% of the group with HF and 84% of controls remained in sinus rhythm, and the HF patients also improved significantly in NYHA functional class, LVEF, and echocardiographic measures of ventricular remodeling. Patients in both groups benefited with significantly higher exercise-test results and quality-of-life scores.

Cath ablation's apparent effect on LVEF was independent of whether a patient had coexisting structural heart disease other than dilated cardiomyopathysuch as coronary disease, valvular disease, or hypertrophic cardiomyopathy.

Mean functional and echocardiographic changes, patients with atrial fibrillation and HF (n=58)

Parameter Mean change p
  -0.9 <0.001
  +21 <0.001
  +11 <0.001
  -6 0.03
  -8 <0.001

 

 

*Benefit persisted to 1 year

 

LVEDD=left ventricular end-diastolic diameter

 

LVESD=left ventricular end-systolic diameter

 

Although its patients may not be typical of those with both atrial fib and HF, the study suggests some can benefit from rhythm control achieved through catheter ablation if adverse effects can be avoided, Drs William G Stevenson and Lynne W Stevenson (Brigham and Women's Hospital, Boston, MA) write in an accompanying editorial[2]. Periprocedural complications in the study included cardiac tamponade that required drainage in one patient with and another without HF and one stroke in an HF patient.

 
Further improvements are needed to make ablation easier and safer before it will be available outside highly experienced centers.
 

Urging caution in adopting the reported ablation strategy, the editorialists note that it is relatively new, still evolving, and technically challenging. "Further improvements are needed to make ablation easier and safer before it will be available outside highly experienced centers."

Implications of rate-control status

Among the 53 HF patients who entered the study with "persistent or permanent" atrial fib, both those with adequate and inadequate rate control benefited with significantly improved LVEF after ablation. Dilated cardiomyopathy without other structural heart disease predominated among patients with poor rate control, whereas the other structural disorders tended to be present in those with adequate rate control.

Impact of precath ablation rate control* on LVEF, HF subgroup with "persistent or permanent" atrial fibrillation

End point Inadequate rate control (n=29) Adequate rate control (n=24) p
  +23 +17 <0.001

 

 

*Defined as resting mean ventricular rate <80 beats per minute over 48 hours prior to ablation

 

A full 92% of patients with both poor preablation rate control and no coexisting structural heart disease showed significantly improved ventricular function. The finding, according to the Bordeaux team, "suggests that congestive heart failure was attributable primarily to tachycardia-mediated cardiomyopathy in this group of patients."

Mean exercise and quality-of-life* outcomes at 1 year

Outcome Atrial fib plus HF (n=58) Atrial fib, no HF (n=58)
  3 (<0.001) 2 (0.001)
  21 (<0.001) 13 (<0.001)
  24 (<0.001) 18 (0.003)
  21 (<0.001) 14 (0.004)

 

 

*Short-Form General Health Survey quality-of-life questionnaire

 

Mean changes in LVEF by presence or absence of structural heart disease*

Group Atrial fib plus HF p
  +24 <0.001
  +16 <0.001

 

 

*Other than dilated cardiomyopathy

 

To download tables as slides, click on slide logo below

 

Hsu reported receipt of lectureship fees from Biosense Webster Inc. William G Stevenson reported receipt of consulting and lecture fees as well as grant support from Biosense Webster and lecture fees from CryoCath Technologies Inc. Lynne W Stevenson reported receipt of consulting fees and grant support from Medtronic Inc.

 

 

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