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Pulmonary vein isolation beats AV node ablation for drug-refractory AF in HF patients
23 October 2008
MedWire News: Pulmonary vein isolation is superior to atrioventricular (AV) node ablation with biventricular pacing for the treatment of drug-refractory atrial fibrillation (AF) in patients with heart failure (HF), conclude researchers.
Mohammed Khan (Cardiovascular Associates, Elk Grove Village, Illinois, USA) and co-investigators report that pulmonary vein isolation, “a form of rhythm control,” provides morphologic, functional, and quality-of-life improvements compared with the “extreme form of rate-control strategy and of rate-regularization” involving AV node ablation with implantation of a biventricular implantable cardioverter defibrillator.
Pulmonary vein isolation also resulted in high rates of freedom from both AF and antiarrhythmic medications, the authors write in the New England Journal of Medicine.
“In such a population, pulmonary vein isolation should be strongly considered at experienced centers,” they contend.
The researchers randomly assigned patients with New York Heart Association Class II or III HF, with an ejection fraction of 40% or less, and symptomatic AF despite antiarrhythmic therapy, to undergo either procedure.
In all, 41 patients underwent pulmonary vein isolation and 40 underwent AV node ablation with biventricular pacing.
All patients undergoing AV-node ablation had continuation of AF at 6 months. In contrast, 88% of patients who underwent pulmonary vein isolation were free from AF with or without antiarrhythmic drugs, including 71% who were free of AF without arrhythmic drugs.
The composite primary endpoint favored pulmonary vein isolation, with significant improvements at 6 months in left ventricular ejection fraction, 6-minute-walk distance, and Minnesota Living with HF questionnaire score when compared with AV-node ablation and biventricular pacing, at 35% versus 28%, 340 m versus 297 m, and 60 versus 82, respectively (all p<0.001).
Khan and team say the unexpectedly frequent progression of AF in patients who underwent AV-node ablation with biventricular pacing, seen in 30% of these patients compared with none in the pulmonary vein isolation group, means the former approach is “a less appealing option in centers where experienced AF ablationists are available to perform pulmonary vein isolation, a more definitive ablation procedure.”
