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Ablate and Pace: Is This Still a Valid Option?

  • M. Brignole
Conference paper

Abstract

Atrioventricular (AV) junction ablation (producing AV block) followed by implantation of a pacemaker is a well-established, generally accepted, treatment for patients affected by atrial fibrillation (AF) that is not controlled by antiarrhythmic drugs. Nevertheless, ablation and pacing is a palliative treatment. Indeed, in contrast to other ablative procedures, i.e., those used for the treatment of AV-nodal re-entrant tachycardia and accessory by-pass tracts, in which the ablation can be considered curative, AV junction ablation cannot eliminate the electrophysiological substrate of the disease and only works indirectly by controlling the irregular and fast ventricular rate. In other words, an old disease (uncontrolled AF) is replaced by another disease (iatrogenic AV block and pacemaker dependence). Moreover, the procedure is necessarily associated with a pacemaker implant, and there is a small but definite risk of of short- and long-term complications from the ablative therapy and pacemaker implantation. For these reasons, many cardiologists and electrophysiologists have concerns about wide use of this new treatment and some refute the wisdom of its introduction into clinical practice. It must be remembered that the typical candidate for ablation and pacing is an elderly patient who has frequent (even daily) episodes of symptomatic paroxysmal AF; is very distressed by the arrhythmia, which greatly limits the quality of life; and has been treated unsuccessfully for many years with multiple drug therapies. Apart from AF, frequently no structural heart disease is found, suggesting that rapid and irregular rhythms are the most likely contributory factors in the symptomatology. What should we do for these patients when drugs fail?

Keywords

Atrial Fibrillation Cardiac Resynchronization Therapy Catheter Ablation Paroxysmal Atrial Fibrillation Chronic Atrial Fibrillation 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

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References

  1. 1.
    Prystowsky E, Benson DW, Fuster V et al (1996) Management of patients with atrial fibrillation. A statement for healthcare professionals from the Subcommittee on Electrocardiography and Electrophysiology, American Heart Association. Circulation 93:1262–1277PubMedCrossRefGoogle Scholar
  2. 2.
    Hohnloser S, Kuck KH (2000) Rhythm or rate control in atrial fibrillation. Pharmacological intervention in atrial fibrillation. Lancet 356:1789–1794PubMedCrossRefGoogle Scholar
  3. 3.
    Wyse DG, Waldo AL, DiMarco JP (2002) A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med 347:1825–1833PubMedCrossRefGoogle Scholar
  4. 4.
    van Gelder IC, Hagens VE, Bosker HA (2002) A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. N Engl J Med 347:1834–1840PubMedCrossRefGoogle Scholar
  5. 5.
    Brignole M, Menozzi C, Gasparini M et al (2002) An evaluation of the strategy of maintenance of sinus rhythm by antiarrhythmic drug therapy after ablation and pacing therapy in patients with paroxysmal atrial fibrillation. Eur Heart J 23:892–900PubMedCrossRefGoogle Scholar
  6. 6.
    Carlsson J et al (2001) Mortality and stroke in rate vs rhythm control in AF: the STAF Pilot Study. J Am Coll Cardiol 38:A595CrossRefGoogle Scholar
  7. 7.
    Trohman R, Simmons T, Moore S et al (1992) Catheter ablation of the atrioventricular junction using radiofrequency energy and a bilateral cardiac approach. Am J Cardiol 70:1438–1443PubMedCrossRefGoogle Scholar
  8. 8.
    Souza O, Gursoy S, Simonis F et al (1992) Right-sided versus left-sided radiofrequency ablation of the His bundle. Pacing Clin Electrophisiol 15:1454–1459CrossRefGoogle Scholar
  9. 9.
    Kalbfleisch S, Williamson B, Man C et al (1993) A randomized comparison of the right-and left-sided approaches to ablation of the atrioventricular junction. Am J Cardiol 72:1406–1410PubMedCrossRefGoogle Scholar
  10. 10.
    Brignole M, Gianfranchi L, Menozzi C et al (1994) Influence of atrioventricular junction radiofrequency ablation in patients with chronic atrial fibrillation and flutter on quality of life and cardiac performance. Am J Cardiol 74: 242–24611PubMedCrossRefGoogle Scholar
  11. 11.
    Geelen P, Brugada J, Andries E et al (1997) Ventricular fibrillation and sudden death after radiofrequency catheter ablation of the atrioventricular junction. Pacing Clin Electrophisiol 20:343–348CrossRefGoogle Scholar
  12. 12.
    Darpo B, Walfridsson H, Aunes M et al (1997) Incidence of sudden death after radio-frequency ablation of the atrioventricular junction for atrial fibrillation. Am J Cardiol 80:1174–1177PubMedCrossRefGoogle Scholar
  13. 13.
    Marshall H, Griffith M (1999) Ablation of the atrioventricular junction: technique, acute and long-term results in 115 consecutive patients. Europace 1: 26–29PubMedCrossRefGoogle Scholar
  14. 14.
    Brignole M, Gianfranchi L, Menozzi C et al (1997) An assessment of atrioventricular junction ablation and DDDR mode-switching pacemaker versus pharmacological treatment in patients with severely symptomatic paroxysmal atrial fibrillation. A randomized controlled study. Circulation 96:2617–262PubMedCrossRefGoogle Scholar
  15. 15.
    Olgin J, Scheinman M (1993) Comparison of high energy direct current and radiofrequency catheter ablation of the atrioventricular junction. J Am Coll Cardiol 21:557–564PubMedCrossRefGoogle Scholar
  16. 16.
    Morady F, Calkins H, Langberg J et al (1993) A prospective randomized comparison of direct current and radiofrequency ablation of the atrioventricular junction. J Am Coll Cardiol 21:102–109PubMedCrossRefGoogle Scholar
  17. 17.
    Hindricks G and MERFS investigators (1993) The Multicentre European Radiofrequency Survey (MERFS): complications of radiofrequency catheter ablation of arrhythmias. Eur Heart J 14:1644–1653PubMedCrossRefGoogle Scholar
  18. 18.
    Scheinman M (1994) Patterns of catheter ablation practice in the United States: results of the 1992 NASPE survey. Pacing Clin Electrophisiol 17:873–875CrossRefGoogle Scholar
  19. 19.
    Kay GN, Bubien RS, Epstein AE et al ( 1988) Effect of catheter ablation of the atrioven-tricular junction on quality of life and exercise tolerance in paroxysmal atrial fibrillation. Am J Cardiol 62:741–744PubMedCrossRefGoogle Scholar
  20. 20.
    Jensen SM, Bergfeldt L, Rosenquist M (1995) Long-term follow-up of patients treated by radiofrequency ablation of the atrioventricular junction. Pacing Clin Electrophisiol 18:1609–1614CrossRefGoogle Scholar
  21. 21.
    Fitzpatrick AD, Kourouyan HD, Siu A et al (1996) Quality of life and outcomes after radiofrequency His-bundle catheter ablation and permanent pacemaker implantation: impact of treatment in paroxysmal and established atrial fibrillation. Am Heart J, 131:499–507PubMedCrossRefGoogle Scholar
  22. 22.
    Bubien RS, Knotts-Dolson SM, Plumb VJ et al (1996) Effect of radiofrequency catheter ablation on health-related quality of life and activities of daily living in patients with recurrent arrhythmias. Circulation, 94:1585–1591PubMedCrossRefGoogle Scholar
  23. 23.
    Marshall H, Harris Z, Griffith M et al (1999) Prospective randomized study of ablation and pacing versus medical therapy for paroxysmal atrial fibrillation. Effects of pacing mode and mode-switch algorithm. Circulation 99:1587–1592PubMedCrossRefGoogle Scholar
  24. 24.
    Rosenquist M, Lee M, Mouliner L et al (1990) Long-term follow-up of patients after transcatheter direct current ablation of the atrioventricular junction. J Am Coll Cardiol 16:1467–1474CrossRefGoogle Scholar
  25. 25.
    Natale A, Zimerman L, Tomassoni G et al (1996) Impact on ventricular function and quality of life of transcatheter ablation of the atrioventricular junction in chronic atrial fibrillation with a normal ventricular response. Am J Cardiol 78:1431–1433PubMedCrossRefGoogle Scholar
  26. 26.
    Brignole M, Menozzi C, Gianfranchi L et al (1998) Assessment of atrioventricular junction ablation and WIR pacemaker versus pharmacological treatment in patients with heart failure and chronic atrial fibrillation. A randomized controlled study. Circulation 98:953–960PubMedCrossRefGoogle Scholar
  27. 27.
    Weersoorija R, Davis M, Powell A et al (2003) The Australian intervention randomized control of rate in atrial fibrillation trial (AIRCRAFT). J Am Coll Cardiol (in press)Google Scholar
  28. 28.
    Etienne Y, Mansourati J, Gilard M et al (1999) Evaluation of left ventricular based pacing in patients with congestive heart failure and atrial fibrillation. Am J Cardiol 83:1138–1140PubMedCrossRefGoogle Scholar
  29. 29.
    Leclerq C, Victor F, Alonso C et al (2000) Comparative effects of permanent biventri-cular pacing for refractory heart failure in patients with stable sinus rhythm or chronic atrial fibrillation. Am J Cardiol 85:1154–1156CrossRefGoogle Scholar
  30. 30.
    Lupi G, Brignole M, Oddone D et al (2000) Effects of left ventricular pacing on cardiac performance and quality of life in patients with drug-refractory heart failure. Am J Cardiol 86:33–36CrossRefGoogle Scholar
  31. 31.
    Leclercq C, Walker S, Linde C et al (2002) Comparative effects of permanent biventri-cular and right-univentricular pacing in heart failure patients with chronic atrial fibrillation. Eur Heart J 23:1780–1787PubMedCrossRefGoogle Scholar
  32. 32.
    Brignole M, Gammage M, Jordaens L et al (1999) Sutton R. Report of a study group on ablate and pace therapy for paroxysmal atrial fibrillation. Europace 1:8–13PubMedCrossRefGoogle Scholar
  33. 33.
    Furberg C, Psaty B, Manolio T (1994) Prevalence of atrial fibrillation in elderly subjects (the cardiovascular Heart Study). Am J Cardiol 74:236–241PubMedCrossRefGoogle Scholar
  34. 34.
    Kannel W, Abbott R, Savage D (1983) Coronary heart disease and atrial fibrillation: The Framingham Study. Am Heart J 106:389–396PubMedCrossRefGoogle Scholar
  35. 35.
    Crjins HJ, van Gelder IC, van Gilst WH et al (1991) Serial antiarrhythmic drug treatment to maintain sinus rhythm after electrical cardioversion for chronic atrial fibril-lation or atrial flutter. Am J Cardiol 68:335–341CrossRefGoogle Scholar
  36. 36.
    Inama G (2002) Attività dei laboratori di elettrofisiologia italiani nel 2001. G Ital Aritm Cardiostim 5:231–237Google Scholar
  37. 37.
    Gribbin GM, Bourke JP, McComb J (1998) Predictors of atrial rhythm after atrioven-tricular node ablation for the treatment of paroxysmal atrial arrhythmias. Heart 79:548–553PubMedGoogle Scholar
  38. 38.
    Gianfranchi L, Brignole M, Menozzi C et al (1998) Progression of permanent atrial fibrillation after atrioventricular junction ablation and dual-chamber pacemaker implantation in patients with paroxysmal atrial tachyarrhythmias. Am J Cardiol 81:351–354PubMedCrossRefGoogle Scholar
  39. 39.
    Kamalvand K, Tan K, Kotsakis A (1997) Is mode switching beneficial? A randomised study in patients with paroxysmal atrial tachyarrhythmias. J Am Coll Cardiol 30:496–504PubMedCrossRefGoogle Scholar
  40. 40.
    Weber BE, Kapoor WN (1996) Evaluation and outcome of patients with palpitations. Am JMed, 100:138–148Google Scholar
  41. 41.
    Vanderheiden M, Goethals M, Anguera I et al (1997) Hemodynamic deterioration following radiofrequency ablation of the atrioventricular conduction system. Pacing Clin Electrophisiol 20:2422–2438CrossRefGoogle Scholar
  42. 42.
    Twidale N, Manda V, Nave K et al (1998) Predictors of outcome after radiofrequency catheter ablation of the atrioventricular node for atrial fibrillation and congestive heart failure. Am Heart J 136:647–657PubMedCrossRefGoogle Scholar
  43. 43.
    Zile M, Blaustein A, Shimizu G et al (1987) Right ventricular pacing reduces the rate of left ventricular relaxation and filling. J Am Coll Cardiol 10:702–709PubMedCrossRefGoogle Scholar
  44. 44.
    Ausubel K, Furman S (1985) The pacemaker syndrome. Ann Intern Med 103:420–429PubMedGoogle Scholar
  45. 45.
    Leon A, Greenberg J, Kanaru N et al (2002) Cardiac resynchronization in patients with congestive heart failure and chronic atrial fibrillation. J Am Coll Cardiol 39:1258–1263PubMedCrossRefGoogle Scholar
  46. 46.
    Gasparini M, Mantica M, Brignole M et al (1999) Thromboembolism after atrioventricular node ablation and pacing: long term follow-up. Heart 82:494–498PubMedGoogle Scholar
  47. 47.
    Wood M, Brown-Mahoney C, Kay GN et al (2000) Clinical outcomes after ablation and pacing therapy for atrial fibrillation. Circulation 101:1138–1144.PubMedCrossRefGoogle Scholar
  48. 48.
    Ozcan C, Jahangir A, Friedman PA et al (2001) Long-term survival after ablation of the atrioventricular node and implantation of a permanent pacemaker in patients with atrial fibrillation. N Engl J Med 344:1043–1051PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Italia 2004

Authors and Affiliations

  • M. Brignole
    • 1
  1. 1.Department of Cardiology, Arrhythmologic CentreOspedali del TigullioLavagnaItaly

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