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Atrial Fibrillation Ablation in Patients with Severe Left Ventricular Dysfunction
S92 Journal of Cardiac Failure Vol. 20 No. 8S August 2014
Figure. catheter ablation may likely of great benefit in patients with tachycardia mediated cardiomyopathy from atrial fibrillation.
231 Atrial Fibrillation Ablation in Patients with Severe Left Ventricular Dysfunction Arun Kanmanthareddy1, Avanija R. Buddam1, Madhu Reddy1, Ryan Maybrook1, Ajay Vallakati2, Arun Mahankali Sridhar1, Sandeep Koripalli1, Pramod Janga1, Sudharani Bommana1, Donita Atkins1, Dhanunjaya Lakkireddy1; 1The University of Kansas Medical Center, Kansas City, KS; 2Case Western Reserve University/ MetroHealth Medical Center, Cleveland, OH Table.
Baseline Characteristics
N532 60.4 6 9.3
Age (years) Sex Males Type of AF Paroxysmal Persistent Comorbidities Hypertension Diabetes CAD Stroke Chronic obstructive pulmonary disease Coronary artery bypass surgery ICD Valvular heart surgery Prior atrial fibrillation ablations CHADS2 Score Medications Beta blockers Calcium channel blockers Class III anti-arrhythmics Digoxin Quinidine Aspirin Warfarin New Oral Anticoagulants Mean Follow up duration (months) Death
Rhythm Sinus (with and without anti-arrhythmics) Ejection fraction NYHA class Mean change in ejection fraction
28 (87.5%) 2 (6.3%) 30 (93.7%) 19 (59.4%) 6 (18.48%) 12 (37.5%) 3 (9.4%) 6 (18.8%) 6 (18.8%) 11 (34.4%) 2 (6.3%) 3 (9.4%) 2 6 0.9 29 (90.6%) 6 (18.8%) 20 (62.5%) 17 (53.1%) 3 (9.4%) 14 (43.8%) 30 (93.8%) 2 (6.3%) 27.2 6 13.9 1 (3.1%)
Pre Ablation
Post Ablation
10 (31.3%)
24 (75%)
P ! 0.001
28.4 6 6% 3.2 6 0.5
46.6 6 13.6% 1.8 6 0.3 18.1 6 14.5%
P ! 0.001 P ! 0.001
Introduction: Atrial fibrillation increases morbidity and mortality in patients with congestive heart failure. The impact of catheter ablation in patients with severe left ventricular dysfunction (ejection fraction # 35%) and atrial fibrillation has not
been studied before. Methods: This is a prospective, observational study of patients with severe heart failure with an ejection fraction # 35% undergoing catheter ablation of atrial fibrillation. Patient records were reviewed for baseline variables, comorbidities, medications, EKG and echocardiogram. Follow up visits, EKG, event recorders, device interrogations and echocardiograms were reviewed for all these patients following catheter ablation. Statistical analysis was done using SPSS 21. Categorical variables were compared using chi square or Fishers exact test and continuous variables were compared using t-test as and when appropriate. Results: A total of 32 patients with ejection fraction # 35% underwent catheter ablation. Pulmonary vein isolation was the standard procedure for all the patients. Additional ablation sites were at the discretion of the operator. Mean age was 60.4 6 9.3 years and were predominantly males (87.5%). Atrial fibrillation was persistent in 93.7% of the subjects. Etiology of cardiomyopathy was ischemic in 37.5% of the patients only. Atrial fibrillation ablation was successful in all the patients and were successfully restored to sinus rhythm. After a follow up duration of 27.2 6 13.9 months, 75% of patients remained in sinus rhythm compared to only 31% patients (with and without anti-arrhythmics) prior to catheter ablation (p!0.001). There was a significant improvement in ejection fraction (46.6 6 13.6% vs 28.4 6 6 %, p ! 0.001) and New York heart association functional class (1.8 6 0.3 vs 3.2 6 0.5, p ! 0.001) after catheter ablation. The mean improvement in ejection fraction was 18.1 6 14.5%. There was only one death during the follow up period. Conclusion: Catheter ablation of atrial fibrillation in patients with severe left ventricular dysfunction results in significant improvement in left ventricular function. Tachycardia mediated cardiomyopathy from atrial fibrillation is likely to be reversed after catheter ablation of atrial fibrillation.
232 Clinical Characteristics of Patients with Atrial Fibrillation on Long-term Ambulatory Monitoring Steven Carlson, Leslie Saxon, Rahul Doshi, Jerold Shinbane, Philip Chang, Evann Eisenberg; USC Keck Medical Center, Los Angeles, CA Introduction: The presence of AF has negative prognostic implications for heart failure patients and ambulatory screening for the presence of AF is not routine. Assessment of symptoms has relied on patient history or short term monitoring diagnostics.We studied the correlation between AF episodes and symptoms using a long-term, ambulatory, continuous recording device. Methods: Data from 524 consecutive patients from the USC electrophysiology practice were reviewed. Patients were instructed to wear the device for up to 14 days and to activate a trigger button on the patch when experiencing symptoms of an arrhythmia such as dizziness, palpitations or fatigue. Ninety-four patients had recorded AF and were included in the analysis. Differences between patients with and without symptoms were analyzed. Results: There are no differences in age, LVEF or medication usage between symptomatic and asymptomatic patients. Most AF patients are asymptomatic and symptomatic patients are more likely to have paroxysmal AF than permanent AF (Table 1). More patients with paroxysmal AF triggered the device during AF episodes compared than those with permanent AF (5 vs. 1.3, p 5 0.005). Conclusion: Longterm continuous ECG monitoring reveals that most AF episodes are asymptomatic and patients with paroxysmal AF have a much higher burden of symptoms than those with permanent AF, despite medication usage. Our data suggest that long-term ECG monitoring for screening can be useful to detect AF in heart failure patients who would not otherwise be targeted for screening on the basis of symptoms or ECG.
Table 1. Comparison between patients with atrial fibrillation with and without symptoms
All No Patients Symptoms Symptoms P (n 5 94) Range (n 5 51) (n 5 43) Value Age (average) LVEF% Medications (n 592) Beta Blocker (%) Amiodarone (%) Calcium Channel Blocker (%) Average of time worn (hours) Permanent AF (%) Paroxysmal AF (%)
69.4 56.4
(33-89) (20-84)
70.6 57.2
68 55.6
0.27 0.55
58 18 13.8
e e e
59 20 17.65
58 16 9.30
0.29 0.38 0.18
165
(26-335)
167
162
0.69
54 43
e e
69 32
44 56
0.02 0.02
Table 2 (232). Permanent atrial fibrillation vs. paroxysmal atrial fibrillation
Average number of triggers
All Patients (n594)
Range
Permanent AF (n554)
Paroxysmal AF (n 5 40)
P Value
2.965.5
(0-33)
1.362.5
567.5
0.005
Figure. catheter ablation may likely of great benefit in patients with tachycardia mediated cardiomyopathy from atrial fibrillation.
231 Atrial Fibrillation Ablation in Patients with Severe Left Ventricular Dysfunction Arun Kanmanthareddy1, Avanija R. Buddam1, Madhu Reddy1, Ryan Maybrook1, Ajay Vallakati2, Arun Mahankali Sridhar1, Sandeep Koripalli1, Pramod Janga1, Sudharani Bommana1, Donita Atkins1, Dhanunjaya Lakkireddy1; 1The University of Kansas Medical Center, Kansas City, KS; 2Case Western Reserve University/ MetroHealth Medical Center, Cleveland, OH Table.
Baseline Characteristics
N532 60.4 6 9.3
Age (years) Sex Males Type of AF Paroxysmal Persistent Comorbidities Hypertension Diabetes CAD Stroke Chronic obstructive pulmonary disease Coronary artery bypass surgery ICD Valvular heart surgery Prior atrial fibrillation ablations CHADS2 Score Medications Beta blockers Calcium channel blockers Class III anti-arrhythmics Digoxin Quinidine Aspirin Warfarin New Oral Anticoagulants Mean Follow up duration (months) Death
Rhythm Sinus (with and without anti-arrhythmics) Ejection fraction NYHA class Mean change in ejection fraction
28 (87.5%) 2 (6.3%) 30 (93.7%) 19 (59.4%) 6 (18.48%) 12 (37.5%) 3 (9.4%) 6 (18.8%) 6 (18.8%) 11 (34.4%) 2 (6.3%) 3 (9.4%) 2 6 0.9 29 (90.6%) 6 (18.8%) 20 (62.5%) 17 (53.1%) 3 (9.4%) 14 (43.8%) 30 (93.8%) 2 (6.3%) 27.2 6 13.9 1 (3.1%)
Pre Ablation
Post Ablation
10 (31.3%)
24 (75%)
P ! 0.001
28.4 6 6% 3.2 6 0.5
46.6 6 13.6% 1.8 6 0.3 18.1 6 14.5%
P ! 0.001 P ! 0.001
Introduction: Atrial fibrillation increases morbidity and mortality in patients with congestive heart failure. The impact of catheter ablation in patients with severe left ventricular dysfunction (ejection fraction # 35%) and atrial fibrillation has not
been studied before. Methods: This is a prospective, observational study of patients with severe heart failure with an ejection fraction # 35% undergoing catheter ablation of atrial fibrillation. Patient records were reviewed for baseline variables, comorbidities, medications, EKG and echocardiogram. Follow up visits, EKG, event recorders, device interrogations and echocardiograms were reviewed for all these patients following catheter ablation. Statistical analysis was done using SPSS 21. Categorical variables were compared using chi square or Fishers exact test and continuous variables were compared using t-test as and when appropriate. Results: A total of 32 patients with ejection fraction # 35% underwent catheter ablation. Pulmonary vein isolation was the standard procedure for all the patients. Additional ablation sites were at the discretion of the operator. Mean age was 60.4 6 9.3 years and were predominantly males (87.5%). Atrial fibrillation was persistent in 93.7% of the subjects. Etiology of cardiomyopathy was ischemic in 37.5% of the patients only. Atrial fibrillation ablation was successful in all the patients and were successfully restored to sinus rhythm. After a follow up duration of 27.2 6 13.9 months, 75% of patients remained in sinus rhythm compared to only 31% patients (with and without anti-arrhythmics) prior to catheter ablation (p!0.001). There was a significant improvement in ejection fraction (46.6 6 13.6% vs 28.4 6 6 %, p ! 0.001) and New York heart association functional class (1.8 6 0.3 vs 3.2 6 0.5, p ! 0.001) after catheter ablation. The mean improvement in ejection fraction was 18.1 6 14.5%. There was only one death during the follow up period. Conclusion: Catheter ablation of atrial fibrillation in patients with severe left ventricular dysfunction results in significant improvement in left ventricular function. Tachycardia mediated cardiomyopathy from atrial fibrillation is likely to be reversed after catheter ablation of atrial fibrillation.
232 Clinical Characteristics of Patients with Atrial Fibrillation on Long-term Ambulatory Monitoring Steven Carlson, Leslie Saxon, Rahul Doshi, Jerold Shinbane, Philip Chang, Evann Eisenberg; USC Keck Medical Center, Los Angeles, CA Introduction: The presence of AF has negative prognostic implications for heart failure patients and ambulatory screening for the presence of AF is not routine. Assessment of symptoms has relied on patient history or short term monitoring diagnostics.We studied the correlation between AF episodes and symptoms using a long-term, ambulatory, continuous recording device. Methods: Data from 524 consecutive patients from the USC electrophysiology practice were reviewed. Patients were instructed to wear the device for up to 14 days and to activate a trigger button on the patch when experiencing symptoms of an arrhythmia such as dizziness, palpitations or fatigue. Ninety-four patients had recorded AF and were included in the analysis. Differences between patients with and without symptoms were analyzed. Results: There are no differences in age, LVEF or medication usage between symptomatic and asymptomatic patients. Most AF patients are asymptomatic and symptomatic patients are more likely to have paroxysmal AF than permanent AF (Table 1). More patients with paroxysmal AF triggered the device during AF episodes compared than those with permanent AF (5 vs. 1.3, p 5 0.005). Conclusion: Longterm continuous ECG monitoring reveals that most AF episodes are asymptomatic and patients with paroxysmal AF have a much higher burden of symptoms than those with permanent AF, despite medication usage. Our data suggest that long-term ECG monitoring for screening can be useful to detect AF in heart failure patients who would not otherwise be targeted for screening on the basis of symptoms or ECG.
Table 1. Comparison between patients with atrial fibrillation with and without symptoms
All No Patients Symptoms Symptoms P (n 5 94) Range (n 5 51) (n 5 43) Value Age (average) LVEF% Medications (n 592) Beta Blocker (%) Amiodarone (%) Calcium Channel Blocker (%) Average of time worn (hours) Permanent AF (%) Paroxysmal AF (%)
69.4 56.4
(33-89) (20-84)
70.6 57.2
68 55.6
0.27 0.55
58 18 13.8
e e e
59 20 17.65
58 16 9.30
0.29 0.38 0.18
165
(26-335)
167
162
0.69
54 43
e e
69 32
44 56
0.02 0.02
Table 2 (232). Permanent atrial fibrillation vs. paroxysmal atrial fibrillation
Average number of triggers
All Patients (n594)
Range
Permanent AF (n554)
Paroxysmal AF (n 5 40)
P Value
2.965.5
(0-33)
1.362.5
567.5
0.005