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Background Pulmonary-vein isolation is increasingly being used to treat atrial fibrillation in patients with heart failure.
Methods In this prospective, multicenter clinical trial, we randomly assigned patients with symptomatic, drug-resistant atrial fibrillation, an ejection fraction of 40% or less, and New York Heart Association class II or III heart failure to undergo either pulmonary-vein isolation or atrioventricular-node ablation with biventricular pacing. All patients completed the Minnesota Living with Heart Failure questionnaire (scores range from 0 to 105, with a higher score indicating a worse quality of life) and underwent echocardiography and a 6-minute walk test (the composite primary end point). Over a 6-month period, patients were monitored for both symptomatic and asymptomatic episodes of atrial fibrillation.
Results In all, 41 patients underwent pulmonary-vein isolation, and 40 underwent atrioventricular-node ablation with biventricular pacing; none were lost to follow-up at 6 months. The composite primary end point favored the group that underwent pulmonary-vein isolation, with an improved questionnaire score at 6 months (60, vs. 82 in the group that underwent atrioventricular-node ablation with biventricular pacing; P<0.001), a longer 6-minute-walk distance (340 m vs. 297 m, P<0.001), and a higher ejection fraction (35% vs. 28%, P<0.001). In the group that underwent pulmonary-vein isolation, 88% of patients receiving antiarrhythmic drugs and 71% of those not receiving such drugs were free of atrial fibrillation at 6 months. In the group that underwent pulmonary-vein isolation, pulmonary-vein stenosis developed in two patients, pericardial effusion in one, and pulmonary edema in another; in the group that underwent atrioventricular-node ablation with biventricular pacing, lead dislodgment was found in one patient and pneumothorax in another.
Conclusions Pulmonary-vein isolation was superior to atrioventricular-node ablation with biventricular pacing in patients with heart failure who had drug-refractory atrial fibrillation. (ClinicalTrials.gov number, NCT00599976
[ClinicalTrials.gov]
.)
Source Information
From Cardiovascular Associates, Elk Grove Village, IL (M.N.K.); Hôpital Cardiologique du Haut-Leveque, Bordeaux, France (P.J., M.H.); Cleveland Clinic, Cleveland (J.C., L.D.B., D.O.M., O.W., R.S., W.S., R.C.S.); University of Foggia, Foggia (L.D.B.), Umberto I Hospital, Mestre-Venice (S.T., A.B., M.C., A.R.), Casa Sollievo della Sofferenza, San Giovanni Rotondo (R.F., D.P., R.M.), Catholic University, Campobasso (P. Santarelli), and Catholic University of the Sacred Heart Rome, Rome (A.D.R., G.P.) — all in Italy; Royal Adelaide Hospital, Adelaide, Australia (P. Sanders); Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); Sutter Pacific Heart Centers, San Francisco (S.H., S.B.); Stanford University Medical Center, Stanford, CA (P.W., A.A.-A., A.N.); Klinikum Coburg, Coburg, Germany (J.B., V.S.); and Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, and Case Western Reserve University, Cleveland (A.N.).
Address reprint requests to Dr. Khan at Cardiovascular Associates, 701 Biesterfield Rd., Elk Grove Village, IL 60007, or at mnktx{at}yahoo.com.
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