Catheter Ablation of Atrial Fibrillation Improves Left Ventricular Function in Patients with Left Ventricular Dysfunction

Catheter Ablation of Atrial Fibrillation Improves Left Ventricular Function in Patients with Left Ventricular Dysfunction

The 18th Annual Scientific Meeting  HFSA S91 Electrophysiology and Rhythm Devices II 228 Role of Atrioventricular Junction Ablation in Patients w...

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The 18th Annual Scientific Meeting



HFSA

S91

Electrophysiology and Rhythm Devices II 228 Role of Atrioventricular Junction Ablation in Patients with Atrial Fibrillation Undergoing Cardiac Resynchronization Therapy? - A Meta-Analysis Ajay Vallakati, Prasanna Sengodan, Mark Dunlap; Metrohealth Medical Center, Cleveland, OH Introduction: Current guidelines from the American College of Cardiology/American Heart Association/Heart Rhythm Society and the European Society of Cardiology (Class IIa, Level of Evidence: B) recommend the use of cardiac resynchronization therapy (CRT) in atrial fibrillation (AF) patients with LVEF #35% and ventricular dyssynchrony. However, both guidelines suggest that atrioventricular junction ablation (AVJA) may be required to ensure complete biventricular capture in patients with AF. We performed a meta-analysis to assess if AVJA is better than rate lowering drugs in this subset of population. Methods: We searched PubMed, Cochrane library and Embase for all published studies comparing AVJA with rate lowering drugs in patients undergoing CRT for the treatment of HF with AF. Mantel-Haenszel method was used to pool data of mortality, hospitalizations and improvement in ejection fraction (EF) in this population. Results: We identified 6 studies (n51747) which compared CRT + AVJA (n5565) with CRT + rate lowering drugs (n51182). Patients who received AVJA had a similar risk for hospitalizations (OR 0.64, 95% CI 0.13 - 3.08, p50.57) and improvement in EF (Std. Mean difference 0.53, 95% CI 0.61 to 1.67, p50.36) compared to people who underwent CRT + rate lowering drugs. There was no difference in total mortality (OR 0.51, 95% CI 0.22 - 1.22, p50.13) between the two groups. However, cardiac mortality was lower (OR 0.73, 95% CI 0.53 - 0.99, p50.04). Conclusion: CRT with AVJA did not significantly decrease the mortality or hospitalizations compared to CRT with medical therapy alone. Furthermore improvement in EF was similar in both groups. However there was decreased cardiac mortality with AVJA in patients undergoing CRT.

safety and usability in the ICU environment. There were no patient or other ICU issues related to the RF energy or wireless transmission of data. A direct linear correlation (r50.86) between measurements of invasive EVLW and non-invasive RFLW was found. RFLW sensitivity to LW volume change was 90mls, while the change in fluid content between normal and congested lungs historically ranges between 250-500mls. LW did not correlate with SBP, DBP, HR, CO or CI (range r50.12-0.54). Conclusions: An externally applied miniature patch using low energy radiofrequency waves to assess pulmonary congestion was tested in man. RFLW measurements had excellent correlation to invasive standard measurement. The demonstrated accuracy of the RF technology supports its use for high resolution thoracic fluid monitoring. It should improve inhospital pulmonary congestion management, and potentially reduce re-hospitalizations when used for home CHF monitoring.

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230 Catheter Ablation of Atrial Fibrillation Improves Left Ventricular Function in Patients with Left Ventricular Dysfunction Arun Kanmanthareddy1, Avanija R. Buddam1, Madhu Reddy1, Sandeep Koripalli1, Ajay Vallakati2, Arun Mahankali Sridhar1, Sudharani Bommana1, Donita Atkins1, Dhanunjaya Lakkireddy1; 1The University of Kansas Medical Center, Kansas City, KS; 2Case Western Reserve University/MetroHealth Medical Center, Cleveland, OH

Figure.

229 Noninvasive Lung Water Determination Using Novel Radiofrequency Technology: Clinical Validation Kent Volosin1, Michael Jonas2, Asaph Nini2, Michal Shohat3, Nimrod Adi2, Galia Karp2; 1Shore Medical Center, Somers Point, NJ; 2Kaplan Medical Center, Rehovot, Israel; 3Kyma Medical Technologies, Los Altos, CA Pulmonary congestion/edema is an acute increase in extravascular lung water (LW). No direct, reliable, simple, and non-invasive method is available for accurate assessment of LW. A miniature external patch device, which monitors LW by analyzing radiofrequency (RF) signals propagated through pulmonary tissue was tested. This study compared non-invasively determined RF LW measurements with invasive assessment of extravascular lung water (EVLW) in ICU patients. Methods: Patients in an ICU with a clinical indication for invasive PiCCO monitoring were studied. A remote wireless patch was placed on the patients’ left chest. This patch emits low energy radiofrequency waves (!10 milliwatts) that reflect from the lung tissue back to the patch. These return signals can be used to estimate LW. RF LW determination was compared to invasive EVLW from 36 patients (20 male; age 63 6 13, range 27-90 years). Measurements of EVLW, cardiac output, systolic and diastolic BP, HR were recorded every 30 minutes. Results: RFLW patch demonstrated excellent

Introduction: Tachycardia mediated cardiomyopathy is an important complication of atrial arrhythmias like atrial fibrillation. Studies evaluating the impact of catheter ablation of atrial fibrillation in patients with left ventricular dysfunction are limited by small sample sizes. A meta-analysis of all published studies was therefore done to assess the impact of catheter ablation in this group of patients. Methods: Literature search for published studies assessing the impact of left ventricular function after catheter ablation was done in the PubMed, Embase, Google Scholar and Cochrane databases. Inclusion criteria applied was catheter ablation in patients with left ventricular dysfunction # 50%. A pooled meta-analysis was done using Comprehensive Meta-Analysis 2 software using random effects model. Results: Total of 13 studies were included in the final meta-analysis. Cumulative number of patients was 621. All the studies uniformly showed an improvement in ejection fraction. The mean improvement in ejection fraction after catheter ablation of atrial fibrillation was 13.9 (95% CI 10 - 17.8, p !0.001). There was significant heterogeneity between the studies (I2593.3, p !0.001). Funnel plot demonstrated symmetric distribution of the studies around the cumulative mean, thus publication bias is unlikely in the included studies. Conclusion: Catheter ablation of atrial fibrillation improves left ventricular function in patients with reduced left ventricular function. Therefore

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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