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OUR MISSION: TO REDUCE THE BURDEN OF CARDIOVASCULAR DISEASE
Dr. Michele Brignole,
Biventricular pacing following atrioventricular junction catheter ablation in uncorrected atrial fibrillation despite RV pacing, or in severe cases of atrial fibrillation - with heart failure, depressed ejection fraction or wide QS -, are effective therapy in patients with uncontrolled and permanent atrial fibrillation.
Incidence of atrial fibrillation per 1000 person-years is 3.1 and 1.9 in 64-year-old men and women respectively, 19.2 in the 65-74 age bracket, and 31.4 in the over 80 population, which in Europe, roughly equates to six million and three and a half in the US, and figures are expected to rise as the population continues to age (1,2,3). Sixty percent of these have a permanent form of it, and forty per cent of these patients display severe symptoms, patients with uncontrolled congestive heart failure included. The initial challenge is to properly detect patients who could benefit from AV junction ablation and pacing. In a prospective, observational, transversal study on the management of AF as primary diagnosis in Italy, we enrolled consecutive in- and out-patients referred to 43 different cardiology departments (4). Although it was observed that atrioventricular (AV) junction ablation and pace-maker implantation had been indicated in 8.6% of patients according to class I indication of Italian guidelines (5) only 2.7% were recommended the intervention by the attending cardiologist. Study results reflect the portion of the physician body who might not refer for intervention because they consider that AV junction ablation merely a palliative or even a potentially harmful. According to guidelines (5), the patients candidates to AV junction ablation are those who: 1) due to high and irregular ventricular rate, had severe symptoms of palpitations, fatigue and shortness of breath during physical activity and at rest with chest discomfort greatly impairing quality of life; Or 2) having a CRT indication due to drug-refractory heart failure, depressed left ventricular (LV) function and wide QRS complexes, have the need to avoid competitive atrial rhythm in order to assure a constant biventricular pacing In fact, randomised observational studies from the last two decades having enrolled in total over a thousand patients have shown that, AV junction ablation and permanent pacing from the RV apex provide efficient rate control, regularisation of AF and improve symptoms without deterioration of the ventricular function (6-13). In a recent sub-analysis of the APAF trial (14), when compared with the pre-ablation evaluation in quality of life scores, great improvement in exercise capacity and cardiac performance was observed at 6 months (Table 1). However, AV junction ablation and permanent right ventricular (RV) pacing cause a non-physiologic asynchronous contraction which might partly counteract any beneficial effects of ablation. Indeed, right ventricular pacing induces a ventricular activation sequence resembling that of left bundle branch block, i.e. the right ventricle is activated before the left, thus causing inter-ventricular dyssynchrony. Likewise, the LV septum is activated before the LV free wall causing intraventricular dyssynchrony. Resynchronisation therapy (CRT) achieved through AV junction ablation can restore proper synchrony. In a sub-analysis on 171 patients of the recent APAF trial (14), 63% of patients had improved clinical conditions, 9% had no change and 28 % worsened with RV pacing during a median follow-up of 20 months. With biventricular pacing however, 83% improved, 5% had no change and 12 % had a worsened clinical condition (p=0.001 versus RV pacing). Furthermore, beneficial effects from CRT were consistent in patients who met the current recommendations from expert consensus for CRT, ejection fraction ≤35%, NYHA class ≥III and QRS width ≥120, (class IIa, level of evidence B), as well as in those who did not. In patients affected by severely symptomatic permanent AF, patients had a greater benefit from AV junction ablation and CRT pacing than RV-paced patients irrespective of the severity of the underlying structural heart disease and of current guidelines criteria. After multivariable analysis, only the CRT mode remained an independent predictor of clinical benefit (p=0.001). As no clinical difference was observed in the outcome of patients treated with biventricular pacing who met the current guideline indications, with those who did not, the results from the APAF study suggest that the indications for CRT should be extended to all patients with severely symptomatic AF undergoing AV junction ablation. Nevertheless, considering the higher costs and complications of CRT, an alternative strategy of CRT upgrading may be a reasonable clinical option in patients who, for any reason, were initially paced at the RV only. “Upgrading” to BiV pacing in patients who developed heart failure months or years after AV junction ablation resulted in a clinical benefit similar to that of “de-novo” CRT pacing (16,17,18). Leon et al (16) had upgraded 20 patients who became severely symptomatic 17 months after AV junction ablation and RV pacing to BiV pacing; they observed an improvement of NYHA class of 29%, of Minnesota LHFQ score of 33% and a reduction of hospitalisation of 81%. Similar results were obtained more recently by Valls-Bertault V et al and by Frohlich G et al (17, 18). In the 2011 APAF sub-analysis (14), upgrade was performed in 14 patients who had developed “clinical failure” after a median of 12 months of RV pacing (Table 2); after 3 months, these patients showed a significant reduction in specific AF symptoms and an improvement in cardiac performance similar to that observed in “de novo” CRT pacing shown in Table 1. Table 1. Changes between baseline and 6-month follow-up after AV junction ablation in 158 patients.
Minnesota LHFQ (Minnesota Living With Heart Failure Questionnaire) scores range from 0 to 105 higher scores indicating worse health status Specific Symptom Scalescores range from 0 to 60 (total score) each item ranging from 0 to 10, higher scores indicating worse health status.
Our current decision-making algorithm used in clinical practice is summarised in Figure 1. Figure 1: AV junction ablation and pacemaker therapy in patients with permanent AF
1. Benjamin EJ, Levy D, Vaziri SM, D'Agostino RB, Belanger AJ, Wolf PA. Independent risk factors for atrial Fibrillation in a population-based cohort: the Framingham heart study. JAMA 1994; 271: 840±4. 2. Feinberg WM, Blackshear JL, Laupacis A, Kronmal R, Hart RG. Prevalence, age distribution, and gender of patients with atrial fibrillation. Analysis and implications. Arch Intern Med 1995; 155: 469-73. 3. Savelieva I, Camm J. Clinical trends in atrial Fibrillation at the turn of the millennium. J Intern Med 2001; 250: 369±372 4. Bottoni N, Tritto M, Ricci R, Accogli M, , Di Biase M, Iacopino S, Iori M, Themistoclakis S, Sitta N, Spadacini G, De Ponti R, Brignole M. Adherence to guidelines for atrial fibrillation management of patients referred to cardiology departments: Studio Italiano multicentrico sul Trattamento della Fibrillazione Atriale (SITAF). Europace 2010; 12, 1070–1077 5. Disertori M, Alboni P, Botto G, Brignole M, Cappucci A, Delise P. Linee Guida AIAC 2006 sul trattamento della fibrillazione atriale. GIAC (Giornale Italiano Aritmologia e Cardiostimolazione) 2006; 9: 1–45. 6. Brignole M, Menozzi C, Gianfranchi L, Musso G, Mureddu R, Bottoni N, Lolli G. Assessment of atrioventricular junction ablation and VVIR pacemaker versus pharmacological treatment in patients with heart failure and chronic atrial fibrillation: a randomized, controlled study. Circulation 1998; 98: 953-960. 7. Brignole M, Gianfranchi L, Menozzi C, Alboni P, Musso G, Bongiorni MG, Gasparini M, Raviele A, Lolli G, Paparella N, Acquarone S. 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 1997;96:2617-2624. 8. Kay GN, Ellenbogen KA, Giudici M, Redfield MM, Jenkins LS, Mianulli M, Wilkoff B. The Ablate and Pace Trial: a prospective study of catheter ablation of the AV conduction system and permanent pacemaker implantation for treatment of atrial fibrillation. APT Investigators. J Interv Card Electrophysiol 1998; 2: 121-135. 9. Ozcan C, Jahangir A, Friedman PA, Patel PJ, Munger TM, Rea RF, Lloyd MA, Packer DL, Hodge DO, Gersh BJ, Hammill SC, Shen WK. Long-term survival after ablation of the atrioventricular node and implantation of a permanent pacemaker in patients with atrial fibrillation. N Engl J Med 2001; 344: 1043–1051. 10. Wood MA, Brown-Mahoney C, Kay GN, Ellenbogen KA. Clinical outcomes after ablation and pacing therapy for atrial fibrillation: a meta-analysis. Circulation 2000; 101: 1138-1144. 11. Tan E, Rienstra M, Wiesfeld AC, Schoonderwoerd BA, Hobbel HH, Van Gelder IC. Long-term outcome of AV node ablation and pacing for symptomatic refractory AF. Europace 2008; 10: 412-8µ 12. Chen L, Hodge D, Jahangir A, Ozcan C, Trusty J, Friedman P, Rea R, Bradley D, Brady P, Hammill S, Hayes D, Shen WK. Preserved left ventricular ejection fraction following atrioventricular junction ablation and pacing for atrial fibrillation. J Cardiovasc Electrophysiol 2008; 19: 19-27 13. Bradley D, Shen WK. Atrioventricular junction ablation combined with either right ventricular pacing or cardiac resynchronization therapy for atrial fibrillation: The need for large-scale randomized trials. Heart Rhythm 2007;4:224 –232 14. Brignole M, Botto GL, Mont L, Oddone D, Iacopino S, De Marchi G, Campoli M, Sebastiani V, Vincenti A, Garcia Medina D, Osca Asensi J, Mocini A, Grovale N, De Santo T, Menozzi C. Predictors of clinical efficacy of “Ablate and Pace” therapy in patients with permanent atrial fibrillation. Heart 2011; 10.1136/heartjnl-2011-301069 (ahead of print) 15. Brignole M, Botto GL, Mont L, Iacopino S, De Marchi G, Oddone D, Luzi M, Tolosana JM, Navazio A, Menozzi C. Cardiac resynchronization therapy in patients undergoing AV Junction ablation for permanent atrial fibrillation: A randomized trial Eur Heart J 2011; 32: 2420–2429 16. Leon AR, Greenberg JM, Kanuru N, Baker CM, Mera FV, Smith AL, Langberg JJ, DeLurgio DB. Cardiac resynchronization in patients with congestive heart failure and chronic atrial fibrillation: effect of upgrading to biventricular pacing after chronic right ventricular pacing. J Am Coll Cardiol 2002; 39: 1258-63 17. Valls-Bertault V, Fatemi M, Gilard M, Pennec PY, Etienne Y, Blanc JJ. Assessment of upgrading to biventricular pacing in patients with right ventricular pacing and congestive heart failure after atrioventricular junctional ablation for chronic atrial fibrillation. Europace 2004; 6: 438-43 18. Frohlich G, Steffel J, Hurlimann D, Enseleit F, Luscher T, Ruschitzka F, Abraham W, Holzmeister J. Upgrading to resynchronization therapy after chronic right ventricular pacing improves left ventricular remodelling. Eur Heart J 2010; 31: 1477–1485
Dr M. Brignole, Lavagna, Italy – Fellow of the European Society of Cardiology. Author disclosure: none.
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