Atrioventricular Node Ablation Research Articles

His bundle pacing and AV nodal ablation for non-controlled atrial arrhythmia: a technical challenge with major clinical benefits

Abstract Funding Acknowledgements Type of funding sources: None. Background His bundle pacing (HBP) is an appealing alternative to right ventricular pacing in patients referred for permanent ventricular pacing and AV nodal ablation (AVNA) as it preserves physiological ventricular activation. Only limited amount of data is available in the literature regarding HBP combined with AVNA. Purpose To provide further evidence on the feasibility and efficacy of this therapeutic approach in patients with uncontrolled atrial arrhythmia. Methods We prospectively included all patients who underwent AVNA after HBP in three different hospitals between 2017 and 2022. Results AVNA following HBP lead implantation was performed in 75 patients. A complete AV block was obtained in 58 patients (77%) whereas significant modulation of the AV node conduction (heart rate < 60bpm) was obtained in 12 (16%). AVNA failure was observed in 5 (7%). The recording of an atrial signal by the HBP lead was more frequently observed in patients with AVNA modulation/failure compared to patients with complete AV block (11/17 vs 5/58; p < 0.001). There was no lead dislodgment during the AVNA procedures. Acute HB capture threshold increase > 1V occurred in 11 patients (15%) with return to baseline value at day one in 9. NYHA class and LVEF significantly improved from baseline to last follow-up (3.0 ± 0.7 vs 1.6 ± 0.5, p < 0.001; 47 ± 14% vs 60 ± 9%; p < 0.0001, respectively), Conclusion AVNA combined with HBP for non-controlled atrial arrhythmia was feasible and clinically efficient. Implanting the HB lead on the ventricular aspect of the tricuspid annulus avoiding atrial signal recording can facilitate AVNA.

Incidence of conversion to sinus rhythm in refractory atrial fibrillation patients after atrioventricular node ablation with conduction system pacing

Abstract Funding Acknowledgements Type of funding sources: None. Background "Ablate and pace" strategy is a reasonable therapeutic option in refractory atrial fibrillation (AF) when rhythm or rate control cannot be achieved with catheter ablation or pharmacological therapy. Atrioventricular node ablation (AVNA) combined with conduction system pacing (CSP), including His-bundle pacing (HBP) and left bundle branch pacing (LBBP), are increasingly adopted, as they offer more physiological activation of the left ventricle compared to other pacing modalities. However, the incidence of conversion to sinus rhythm after "ablate and pace" strategy with CSP is not known. Purpose To determine the incidence of spontaneous conversion to sinus rhythm and its predicting factors in patients undergoing AVNA and CSP. Methods Refractory AF patients undergoing AVNA with CSP at our institution between June 2018 and May 2022 were prospectively included. Echocardiographic and clinical parameters including ECG were assessed at baseline and 6 months after the procedure. Results Sixty-three patients (male 41.3%, age 71±9 years, left ventricle ejection fraction (LVEF) 40% (IQR 20)) were included. Thirty-seven patients (58.7%) received HBP and 26 patients (41.3%) LBBP. During follow-up, spontaneous conversion to sinus rhythm (SR) was registered in 5 patients (8%); 3 in HBP group and 2 in LBBP group. Baseline characteristics of patients who converted to SR did not differ from non-sinus rhythm (NSR) patients except for left atrial volume index (LAVI), which was smaller in SR group (43 mL/m2 (IQR 6) vs. 60 mL/m2 (IQR 19); p<0.01). Multiple regression model confirmed an inverse association between LAVI and conversion to sinus rhythm even after considering other clinically relevant covariates (odds ratio=0.685, p=0.03). At follow-up, LAVI did not change in any group (SR: p=0.345; NSR: p=0.508). LVEF increased in both groups, from 40% (IQR 20) to 51% (IQR 18) in NSR group (p<0.01) and from 41% (IQR 11) to 54% (IQR 11) in SR group (p=0.138), although the increase in SR group did not reach statistical significance due to small sample size. Similarly, ESVi decreased in both groups; in NSR group (from 47 mL/m2 (IQR 33) to 29 mL/m2 (IQR 24), p<0.01) and in SR group (from 33 mL/m2 (IQR 19) to 25 mL/m2 (IQR 0), p=0.176), where statistical significance was not reached due to small sample size and small initial volumes. Symptomatic improvement according to NYHA class was more pronounced in SR group (p=0.026). Conclusion The results of our study show that spontaneous conversion to sinus rhythm after AVNA combined with CSP is not uncommon, especially in patients with smaller left atria. Patients who converted to SR showed superior symptomatic improvement compared to NSR patients. Larger studies are warranted to clarify the predicting variables of SR restoration in these patients, which should be considered for initial atrial pacing lead implantation (dual-chamber device) when "ablate and pace" strategy is adopted.

Coronary sinus cannulation as real time anatomical landmark to facilitate left bundle branch area pacing

Abstract Funding Acknowledgements Type of funding sources: None. Background/Introduction Left bundle branch area pacing (LBBAP) is an established form of conduction system pacing. Innovative fluoroscopic imaging technique with use of radio-opaque contrast in the right ventricle or using pre-mapped His potential has been advocated as an acquired road map to assist in implantation of LBBAP(1) lead. Purpose We aim to explore a different technique by cannulating the coronary sinus (CS) with a sheath and wire to provide real-time anatomical guidance of location of the base of the heart to facilitate more effective LBBAP in a consistent fashion. Methods Prior to LBBAP, the body of the CS is cannulated using an AL2 diagnostic angiographic catheter and a 0.035-inch glidewire. The wire is fixated externally, and fluoroscopic image is acquired before proceeding with deployment of the pacing lead onto an optimal ventricular septal position via standard right (RAO 30) and left anterior oblique (LAO 30) views. From August 2021 to October 2022, we enrolled 12 consecutive patients requiring pacemaker for standard indications and explored the CS cannulation method in delivering LBBAP with either steerable catheters or fixed shape sheaths. Thereafter, we analysed and described the success rates, immediate electrical and device parameters, procedural durations, and clinical events. Results 12 patients were studied. The mean age was 75 ± 13.07 years and 6 (50%) patients were male. 1 (8.3%) was for sinus nodal dysfunction, 10 (83.3%) for atrioventricular block and 1 (8.3%) for atrial fibrillation (AF) control with atrioventricular node ablation. Mean left ventricular ejection fraction was 54.17 ± 8.21 % and baseline QRS was 108.08 ± 23.20ms. LBBAP was successful in all 12 patients based on published criteria with a mean paced QRS duration of 115.25 ± 9.28 ms. The mean total procedure duration was 130.75 +/- 29.84 minutes and mean fluoroscopic duration was 23.17 ± 9.11 minutes. After 1st week post implant, the pacing threshold, sensing, and impedances were stable and acceptable in all the patients. There were no acute complications (e.g. pneumothorax, lead complications, lead dislodgements / perforations) during the periprocedural period. Conclusion(s) The CS cannulation method is a feasible, safe, and effective method to to provide real-time anatomical visualisation of the base of the heart. This facilitates the achievement for optimal LBBAP and can be adopted especially in difficult cardiac anatomies or rotated cardiac silhouettes identified on fluoroscopy.

Acute success, stability and safety of left bundle branch area pacing with steerable catheter and stylet-driven leads: A single center experience

Abstract Funding Acknowledgements Type of funding sources: None. Background/Introduction Right ventricular apical pacing is associated with adverse outcomes and there is an increasing preference to perform conduction system pacing as it allows for more physiological left ventricular activation. His-bundle pacing is known to be technically challenging and results in higher pacing thresholds and increased rates of lead dislodgement. Left bundle branch area pacing (LBBAP) is an emerging alternative form of conduction system pacing. Purpose We aim to study the acute success rates, short-term stability and safety using steerable catheter and stylet-driven (SD) leads for the purpose of LBBAP. Methods 40 consecutive patients who underwent LBBAP with steerable catheter and SD leads in our center from August 2021 to November 2022 were included in this series. Patients’ demographics, pacing indications, baseline QRS morphologies and duration and left ventricular ejection fraction (LVEF) were analysed. Acute success was defined as achieving stimulation to LV activation time (Stim-LVAT) ≤75ms or incomplete right bundle branch paced morphology in V1 [1, 2]. We also reported any left bundle branch (LBB) potential (if present) and the V6-V1 interpeak interval. All lead parameters and complications in the immediate (1 day) and short-term (1 week and 3-6 months) timeframe were evaluated. Results 40 patients' age (mean 72.75), gender (male 52.5%), body mass index (mean 24.15) and LVEF (mean 52.75%) were analysed. Pacing indications included sinus nodal dysfunction (25%), atrioventricular block (70%), heart failure with failed cardiac resynchronisation therapy (CRT) (2.5%) and atrial fibrillation (AF) requiring atrioventricular node ablation (2.5%). We achieved an acute success rate of 87.5% (5% with left ventricular septal pacing, 5% converted to conventional right ventricular septal pacing, and 2.5% converted to CRT). Reasons for failure to achieve successful LBBAP include persistent left superior vena cava, high pacing thresholds or inability to burrow lead into the septum for acceptable V1 morphology and Stim-LVAT due to resistance encountered during turning of the lead. 51.43% patients of the successful LBBAP patients had LBB potential present and/or interpeak interval >33ms [3]. Immediate and short-term lead parameters were stable and acceptable in all cases. There were no complications (such as lead dislodgement, rise in lead impedance or threshold) reported during the acute and short-term follow-up. Conclusion LBBAP is successful in 87.5% of our cases with use of steerable catheter deploying stylet-driven leads and is proven to be a safe and feasible method for conduction system pacing. Incremental experience with the delivery tools will further improve successful implantation. Longer term follow-up of these patients is needed to determine the long-term safety and stability of LBBAP using steerable catheter and stylet-driven leads.

PO-03-023 OUTCOMES OF LEFT BUNDLE BRANCH AREA PACING AND ATRIOVENTRICULAR NODE ABLATION IN PATIENTS WITH GROUP III PULMONARY HYPERTENSION AND ATRIAL FIBRILLATION IN REDUCING RECURRENT HOSPITALIZATION

Data on the feasibility of left bundle branch area pacing (LBBAP) and atrioventricular node (AVN) ablation in patients with pulmonary hypertension (PH) are limited. This study investigated the characteristics and outcomes of LBBAP and AVN ablation in patients with PH. This is a retrospective study of patients with PH and AF who underwent LBBAP and AVN ablation at the Cleveland Clinic between January 1, 2019 and August 1, 2022. Pre-procedural, post-procedural, and follow-up patient data were obtained. A total of 11 patients (mean age 74±10 years old, 100% female) with PH and AF who underwent concomitant LBBAP and AVN ablation were included. The etiology of PH was Group III PH in all patients (55% had COPD and 91% had restrictive lung disease), with the average pulmonary arterial systolic pressure (PASP) of 42 mmHg by echocardiogram, FEV1 of 61.9±17.4% predicted, and FVC of 59.9±7.8% predicted. Baseline ejection fraction was 57±10%, QRS duration was 96±20 ms. Concomitant LBBAP and AVN ablation was successful in all patients. Final implant characteristics included: QRS duration was 124±8 ms, left ventricular activation time was 73.7±5.4 ms; threshold 0.6±0.2 mV @ 0.4 ms and was 0.7±0.2 mV @ 0.4 ms on follow-up; impedance was 618±119 ohms and was 545±145 ohms on follow-up. Prior to the LBBAP and AVN ablation procedure, the average number of AF or heart failure (HF) hospitalizations 24 months prior to the procedure was 4.9±5.3, 64% of patients were on antiarrhythmic drugs, and 100% were on either beta-blockers or calcium channel blockers. During a mean follow-up of 21.9±15.3 months after the LBBAP and AVN ablation procedure, the average AF or HF hospitalization was 0.4±0.9, and all patients were no longer on any antiarrhythmic drugs, beta-blockers, or calcium channel blockers. There were no cases of lead dislodgement. In patients with elevated PA systolic pressure, successful LBBAP and AVN ablation with good two-year outcomes are achievable.Tabled 1Pre LBBAP and AVN ablation*Post LBBAP and AVN ablation**P-valueAF or HF hospitalizations4.9 ± 5.30.4 ± 0.9P<0.01On antiarrhythmic drugs7 (63.6%)0 (0%)P<0.01On rate control drugs11 (100%)0 (0%)NALead dislodgement-0 (0%)NALead capture threshold, mV-0.7 ± 0.2NAValues are mean ± SD or n (%) *24 months prior to LBBAP and AVN ablation **Average follow-up of 22±15 months after LBBAP and AVN ablation Open table in a new tab

AP-452681-1 NIRVANA: LEFT BUNDLE AREA PACING AND ATRIOVENTRICULAR NODAL ABLATION HAS AN EXCELLENT PROCEDURAL SAFETY PROFILE

Conduction system pacing in the form of Left Bundle Area Pacing (LBAP) has become an accepted form of pacing in patients who will have a high degree of pacing from the right ventricle or/and have a history of heart failure. In patients with persistent or poorly controlled AF, that are not ablation candidates or fail medical therapy, atrioventricular nodal (AVN) ablation with permanent pacemaker is an acceptable alternative. LBAP is a more complex procedure than standard right ventricular pacing. Relatively little data exists, on the safety of using LBAP instead of standard right ventricular pacing (RVP) in patients undergoing AVN ablation. To describe the complication profile of left bundle area pacing in comparison to right ventricular with atrioventricular nodal ablation over a six-month follow up at a large volume center. We identified all patients that underwent LBAP or right ventricular pacing with AVN ablation over the last 2 years and had 6 months of follow-up. Left bundle capture was defined by several accepted criteria (septal 3830 leads on or near the left bundle, pacing left ventricular activation timing (pLVAT) ≤80 msec in V5/V6, left bundle potential, appropriate narrowing of the QRS complex). Only patients with AVN ablation who underwent pacemaker implant at the same time (within 24 hours) were included. Any patients with advanced heart failure with severely reduced ejection fraction that failed left ventricular lead placement was excluded from analysis. 156 patients met the inclusion criteria. As illustrated in Table I, 115 patients were in the LBAP group and 41 where in the right ventricular pacing group. Baseline characteristics were not statistically different. The population was predominantly female, had a preserved ejection fraction (EF) and were patients with paroxysmal atrial fibrillation (38.3% LBAP vs 43.9%). Total complications were not different between the groups (5.2% LBAP vs 0% RVP, p=0.34). Absolute complications in any category in any group were low, Figure 1. All complications were seen in the first 30 days post implant, except for a TIA in the LBAP group, seen at 163 days post procedure. Left bundle area pacing as compared to standard right ventricular pacing with concomitant atrioventricular nodal ablation in patients with atrial fibrillation have a similar safety profile during a six month follow-up.

PO-02-156 THE RISE OF LEFT BUNDLE BRANCH AREA "PACE AND ABLATE"; AV NODAL ABLATION OUTCOMES, WHERE ARE WE NOW?

A “pace and ablate” strategy should be considered for those with symptomatic atrial fibrillation (AF) when other therapies have been unsuccessful. Pacemaker induced cardiomyopathy due to RV pacing is a recognised consequence. Left bundle branch area pacing (LBBAP) mitigates this cardiomyopathy compared to RV pacing. As LBBAP becomes more widespread, we expect greater uptake of AV nodal (AVN) ablation “pace and ablate” strategy in those with symptomatic AF. We undertook a multicentre retrospective registry analysis of our patients who underwent AV nodal ablation to assess current real-world procedure data and patient outcomes. We conducted a retrospective multi-centre registry review of outcome data for our patients who underwent AVN ablation over the period of April 2019 until March 2020. We included patients >18 years old who underwent AVN ablation for the purposes of a “pace and ablate” strategy for symptomatic AF despite other strategies. N=52 patients met inclusion criteria. Median age was 74 years (IQR 67, 82), with 28 males. 18 patients had paroxysmal AF, 12 persistent AF and 22 longstanding persistent AF. 10 patients had other documented arrhythmias including arial flutter (4), ventricular tachycardia (3), SVT (2) or atrial tachycardia (1). 9 patients (17%) had previous cardiac surgery including CABG or valve replacements. All patients had successful AVN ablation with durable lesion creation. Radiofrequency was utilised in all patients, with a median application time of 2.67 minutes (IQR: 2, 5.4). Median skin-to-skin procedure time was found to be 55.5 minutes (IQR: 43.75, 73), with a fluoroscopy median time of 3.5 minutes (IQR: 1.55, 6.48). Median radiation dose was 11 mGy (IQR: 4, 16.27). 11 patients had biventricular pacing devices in situ with 41 patients implanted with a conventional pacemaker. There were no acute complications of the procedure. One patient died due to renal failure and one patient had a stroke within 3 months of the procedure but neither of these were directly linked. Our analysis found durable lesion creation with 100% ablation success in our cohort with a median fluoroscopy time of 3.5 minutes and dose of 11 mGy. There were no acute or subacute complications related to the procedure, as far out as 3 months. 11 (21%) patients had biventricular devices with the rest having conventional pacemakers. No patients had conduction system leads implanted, which is likely to change in the coming years.

PO-04-024 THE SMALL HOURS OF THE NIGHT; VENTRICULAR PACING INHIBITION IN A HIS BUNDLE PACEMAKER

Physiologic pacing is a promising alternative to conventional pacing with increasing utilization. We present a novel cause of pacing inhibition discovered after AV node ablation in a permanent His bundle pacing lead. Highlight a rare case of repetitive ventricular pacing inhibition due to internal validation and storage of an intracardiac electrocardiogram on the ventricular channel that occurred in a His bundle pacemaker. N/A An 85-year-old female with paroxysmal AF on flecainide, chronic RBBB, interstitial lung disease, SSS s/p dual chamber pacemaker with a His lead 4 years prior in anticipation of AV node ablation was admitted with highly symptomatic AF with RVR. With failure of both rhythm and rate control, she ultimately underwent successful AV node ablation. Overnight, telemetry showed AS-VP except for hourly events of a single sinus P wave without a following pacing spike or ventricular complex (Figure 1). Atrial and His lead parameters remained normal, and the device was programmed DDDR, not AAIR<-> DDDR. There was no farfield sensing of atrial or His signals on the ventricular channel. The pacemaker manufacturer (Medtronic), noted non-programmable intracardiac electrogram internal validation and storage that can occur every hour plus 30 seconds, but no sooner. During this storage process, ventricular pacing inhibition of a single cycle may occur due to residual electrical disturbance on the ventricular channel from turning on and off EGM collection, unrelated to conventional oversensing of intracardiac signals. The EGM collection must follow an atrial sensed event, consistent with telemetry findings. Thus far it has only been observed with Advisa pacemaker models, which utilizes sensitivity decay based on a ventricular sensed event. Once identified, the RV sensitivity is recommended to be decreased, in this case adjusted from 0.9mV to 2.8mV. This change prevented this phenomenon from re-occurring and the patient was doing well at follow-up 6 months later. This may be more common in His bundle pacing due to smaller R waves, higher V pacing burden, and use of this later model pacemaker. There is a broad differential for failure to pace, especially in a His bundle pacing lead. This case highlights a unique cause of hourly ventricular pacing inhibition, specific to this pacemaker model which may be frequently used in physiologic pacing, unrelated to traditional His lead oversensing.

CE-452776-4 ATRIAL FIBRILLATION IS ASSOCIATED WITH HIGHER INPATIENT MORTALITY AS COMPARED WITH SINUS TACHYCARDIA IN PATIENTS WITH CARDIOGENIC SHOCK

Cardiogenic shock (CS) is commonly associated with a compensatory atrial stress response like sinus tachycardia (ST) or atrial fibrillation (AF). However, there is paucity of data comparing inpatient outcomes in patients with cardiogenic shock presenting with AF versus ST. To compare the impact of AF and ST on in-hospital outcomes in patients admitted with cardiogenic shock. We queried the National Inpatient Sample database to identify primary hospitalizations of CS using ICD-9/ICD-10 CM codes between 2009 and 2019. The study cohort was further divided into three groups based on the concurrent diagnosis of AF, ST, and a comparator group of no AF/ST. Our cohort included a total of 1,376,187 hospitalizations with a diagnosis of CS. Multivariate analysis showed CS hospitalizations with AF as compared with ST, had significantly higher odds of all-cause in-hospital mortality [aOR 1.07 (1.03-1.11) p=0.0005], CRT implantation [aOR 2.38 (1.88-3.03) p<0.001] and AV node ablation [aOR 3.22 (2.63-4.00) p<0.001]. Patients hospitalized with CS without concurrent AF/ST vs concurrent AF had significantly higher odds of all-cause in-hospital mortality [aOR 1.07 (1.06-1.08) p<0.001] and utilization of mechanical circulatory support [aOR 1.33 (1.31-1.34) p<0.001] but lower odds of CRT [aOR 0.76 (0.73-0.80) p<0.001] and AV node ablation [aOR 0.38 (0.37-0.40) p<0.001]. Our data suggest that patients admitted for CS and AF have worse outcomes including higher inpatient mortality, compared to those with CS and ST. However, compared to those without ST or arrhythmias, AF patients had a lower in-hospital mortality. These data are hypothesis generating and merit further study to better inform management of patients with CS and atrial arrhythmias.

Atrioventricular Nodal Ablation Is Not an Effective Treatment Strategy in Catecholaminergic Polymorphic Ventricular Tachycardia.

Catecholaminergic polymorphic ventricular tachycardia is a rare but lethal heritable arrhythmia syndrome associated with both atrial and ventricular arrhythmias. Treatment includes antiarrhythmics, sympathetic denervation, and implantable cardioverter-defibrillators. The use of atrioventricular nodal ablation as a treatment strategy to prevent ventricular arrhythmias in catecholaminergic polymorphic ventricular tachycardia was not found in the literature. This report describes a teenager with a presenting rhythm of atrial and ventricular fibrillation and cardiac arrest. Her clinical arrhythmia was predominantly atrial dysrhythmias, which delayed her diagnosis of catecholaminergic polymorphic ventricular tachycardia. Before her diagnosis, she underwent atrioventricular nodal ablation in an effort to prevent ventricular arrhythmias, which was ultimately ineffective. This report highlights the importance of recognizing atrial arrhythmias in catecholaminergic polymorphic ventricular tachycardia and provides evidence that atrioventricular nodal ablation is not an effective treatment strategy for this disease.

PO-05-018 GIANT INTRASEPTAL HEMATOMA COMPLICATING LEFT BUNDLE BRANCH PACING: AN UNUSUAL CLINICAL CHALLENGE

Left bundle branch pacing (LBBP) is an excellent alternative to His bundle pacing (HBP). Due to its non-traditional intraseptal lead placement, rare but unusual complications have been described. We present the case of a unique complication of a very large septal hematoma following LBBP. n/a An 88-year-old female with Coronary disease, renal insufficiency, and uncontrolled atrial fibrillation was referred for AV node ablation and conduction system pacing. Due to high HBP thresholds, a LBBP lead was implanted in proximal location (Stim-V6 peak=70ms, QRSd=135ms) with a backup second LBBP lead at a slightly distal location (Stim-V6 peak=61ms, QRSd=121ms) with low capture thresholds. She was discharged home the same day. She was readmitted a-day later with nausea, weakness, and significant dyspnea. Echocardiogram revealed a very large septal hematoma (61mm x 40mm) with complete obliteration of right ventricle cavity and no pericardial effusion (Figure 1A). IV fluid bolus was given, and Apixaban/Clopidogrel/ASA were held. Angiography and possible embolization of bleeding septal perforator was considered but not performed due to her CKD and hemodynamic stability. Serial echo revealed improved RV filling, stable hematoma and absent effusion. She was discharged on day 7 in stable condition. Anticoagulation was resumed after 2 weeks. Repeat echo at 6 weeks showed complete resolution of interventricular septal hematoma and lead parameters were stable (Figure 1B). This is a unique and rare case of a giant interventricular septal hematoma post LBBP, successfully managed with conservative management. Given rarity of complication, maintaining a broad differential for early recognition and treatment remains paramount. Avoiding a very proximal and anterior left bundle area, if possible, can be considered to avoid a major septal perforator. Repeat imaging and close hemodynamic monitoring is recommended in such patients. Angiography to localize the bleeding septal perforator and possible embolization may be considered for hemodynamic instability. This was deferred in our patient due to severe renal insufficiency, as well as lack of pericardial effusion and improving hemodynamics not requiring inotropic support. However, we recommend a multidisciplinary heart team and critical care approach, as was used in this case, to help personalize management.

Patients with Rapid Atrial Fibrillation in Congestive Heart Failure with Bilateral Pleural Effusion Complication: Case Report and Literature Review

Highlights: In the setting of AF in patient with AHF, conventional treatment strategies do not convert the rhythm into sinus rhythm. Newly emerged therapies such as catheter ablation, or atrioventricular node ablation with biventricular pacing might be more beneficial rather than the conventional rhythm and rate control strategies Abstract: Atrial fibrillation (AF) is the most common form of arrhythmia. The prevalence of AF in patients with systolic left ventricular dysfunction and CHF is around 35% in the patient population with NYHA II-IV. In this case, we will discuss a case report of a patient with AF with complications of CHF and Bilateral Pleural Effusion. Case Summary. A female patient, 62 years old, came to the emergency room of dr. Soegiri Hospital with complaints of sudden shortness of breath since morning. There were crackles in the right lung field during the auscultation and the chest x-ray shows cardiomegaly with a CTR&gt; 50% with bilateral effusion and atelectasis. On the electrocardiogram examination performed at the ICCU, an irregular rhythm was obtained with an HR of 100x/minute, with p waves that cannot be distinguished, normal QRS waves, and T waves that cannot be assessed. The patient was diagnosed with congestive heart failure (CHF) with rapid atrial fibrillation (AF) accompanied by complications of bilateral pleural effusion with a differential diagnosis of acute decompensated heart failure (ADHF) with pneumonia and acute lung edema (ALO). Discussion. Patients with AF and CHF have a poorer prognosis than patients with a single diagnosis of AF or CHF alone. A rhythm control strategy consisting of antiarrhythmic drugs and electrical cardioversion in stable patients with AF and CHF adds no benefit to a heart rate control strategy.

His-Purkinje conduction system pacing combined with atrioventricular node ablation improves quality of life in older patients with persistent atrial fibrillation refractory to multiple ablation procedures.

Recurrence of atrial fibrillation (AF) is common in patients with persistent AF even after multiple ablation procedures. His-Purkinje conduction system pacing (HPCSP) combined with atrioventricular node ablation (AVNA) is effective in managing patients with AF and heart failure. This study aimed to determine whether HPCSP combined with AVNA can improve quality of life and alleviate symptoms in older patients with symptomatic persistent AF refractory to multiple ablation procedures, as well as evaluate the feasibility and safety of this therapy. Older patients (≥ 65 years) with symptomatic persistent AF refractory to at least two ablation procedures were treated with combined HPCSP and AVNA. The success rates and complications were recorded. Pacing parameters, European Heart Rhythm Association (EHRA) scores, and Atrial Fibrillation Effect on Quality-of-Life (AFEQT) scores obtained perioperatively were compared with those recorded at the 6-month follow-up examination. Thirty-one patients were enrolled; of those, only thirty patients were eventually treated with AVNA because one patient developed a complete atrioventricular block following the withdrawal of the His bundle pacing lead. The success rates were 100% for HPCSP (22 cases with His bundle pacing, and 9 cases with left bundle branch pacing) and 93.3% (28/30) for AVNA, respectively. By the 6-month follow-up examination, EHRA scores improved significantly (3.00 ± 0.73 vs. 2.44 ± 0.63, P = 0.014) and AFEQT scores increased markedly (49.6 ± 20.6 vs. 70.9 ± 14.0, P = 0.001). No severe complications developed. When used in older patients with symptomatic persistent AF refractory to multiple ablation procedures, HPCSP combined with AVNA significantly alleviated symptoms and improved quality of life during short-term follow-up. This therapy was proved to be safe and effective in this patient population.

Beta-blockers increase risk of HF hospitalisation after AV node ablation

Beta-blockers increase risk of HF hospitalisation after AV node ablation

Increased Risk of Heart Failure in Elderly Patients Treated with Beta-Blockers After AV Node Ablation.

Controversy exists regarding the indication of beta-blockers (BB) in different scenarios in patients with cardiovascular disease. We sought to evaluate the effect of BB on survival and heart failure (HF) hospitalizations in a sample of pacemaker-dependent patients after AV node ablation to control ventricular rate for atrial tachyarrhythmias. A retrospective study including consecutive patients that underwent AV node ablation was conducted in a single center between 2011 and 2019. The study's primary endpoints were the incidence of all-cause mortality, first HF hospitalization and the cumulative incidence of subsequent hospitalizations for HF. Competing risk analyses were employed. A total of 111 patients with a mean age of 73.9 years were included in the study. After a median follow-up of 45.5 months, 43 patients had died (38.7%) and 31 had been hospitalized for HF (27.9%). The recurrent HF hospitalization rate was 74/1000 patients/year. Patients treated with BB had a non-significant trend to higher mortality rates and a higher risk of recurrent HF hospitalizations (incidence rate ratio 2.23, 95% confidence interval 1.12-4.44; p = 0.023). After an AV node ablation, the use of BB is associated with an increased risk of HF hospitalizations in a cohort of elderly patients.

Prognostic benefit of catheter ablation of atrial fibrillation in heart failure: An updated meta-analysis of randomized controlled trials.

The prognostic role of catheter ablation of atrial fibrillation (AF) in patients with heart failure (HF) remains uncertain, with guideline recommendations largely based on a single trial. We conducted a meta-analysis of randomized controlled trials (RCTs) assessing the prognostic impact of AF ablation in patients with HF. Electronic databases were searched for RCTs comparing 'AF ablation' versus 'other care' (medical therapy and/or atrioventricular node ablation with pacing) in patients with HF. Primary endpoints were ≥1-year mortality, HF hospitalization and change in left ventricular ejection fraction (LVEF). Meta-analyses were performed using random-effects modelling. Nine RCTs (n= 1462) met inclusion criteria. Compared to 'other care', AF ablation significantly reduced ≥1-year mortality (relative risk [RR] 0.65; 95% confidence intervals [CI], 0.49-0.87) and HF hospitalization (RR 0.64; 95% CI, 0.51-0.81). AF ablation demonstrated significantly greater improvement in LVEF (mean difference [MD] 5.4; 95% CI, 4.4-6.4), 6-min walk test distance (MD 21.5 meters; 95% CI, 4.6-38.4) and quality of life as measured by Minnesota Living with Heart Failure Questionnaire score (MD 7.2; 95% CI, 2.8-11.7). Meta-regression analyses showed the beneficial impact of AF ablation on LVEF was significantly blunted by higher prevalence of ischaemic cardiomyopathy. Our meta-analysis demonstrates AF ablation is superior to 'other care' in improving mortality, HF hospitalization, LVEF and quality of life in patients with HF. However, the highly selected study populations in included RCTs and effect modification mediated by etiology of HF suggests these benefits do not uniformly apply across the HF population.

Atrio-ventricular nodal ablation with biventricular pacing in atrial fibrillation with narrow QRS – a novel strategy to reduce mortality independent of underling left ventricular function.

Historically, clinical studies have demonstrated conflicting results for rate-control versus rhythm-control strategy in patients with permanent atrial fibrillation (AF) in terms of long-term mortality and morbidity. The concept of atrioventricular (AV) nodal ablation coupled with permanent biventricular pacing has recently been advocated as the closest approach to obtain a physiological reset especially in AF patients having underlying ventricular dysfunction. Herein, we present a critical analysis and detailed review based on prior and currently available evidence based on the ablation in permanent atrial fibrillation – cardiac resynchronization therapy (APAF-CRT) mortality trial.

His-Purkinje conduction system pacing and atrioventricular node ablation in treatment of persistent atrial fibrillation refractory to multiple ablation procedures: A case report

In patients with symptomatic atrial fibrillation refractory to optimal medical therapy, atrioventricular node ablation followed by permanent pacemaker implantation is an effective treatment option. A 66-year-old woman with symptomatic persistent atrial fibrillation refractory to multiple ablation procedures was referred to our institution. After optimal drug therapy, the patient still had obvious symptoms. Sequential His-Purkinje conduction system pacing and atrioventricular node ablation were performed. Left bundle branch pacing was used as a backup pacing method if thresholds of His bundle pacing were too high or loss of His bundle capture occurred in the follow-up. At the 6-month follow-up, the European Heart Rhythm Association classification for AF was improved, the score of the Atrial Fibrillation Effect on Quality of Life was enhanced, and the 6-Minute Walk Test was ameliorated. The present case was subjected to His-Purkinje conduction system pacing in combination with atrioventricular node ablation as treatment for a symptomatic persistent atrial fibrillation refractory to multiple ablation procedures, and this procedure alleviated symptoms and improved the quality of life in a short-term follow-up.

His bundle pacing combined with AV node ablation: Feasibility and safety from a multicentric registry

His bundle pacing combined with AV node ablation: Feasibility and safety from a multicentric registry

His bundle pacing versus left bundle branch pacing on ventricular function in atrial fibrillation patients referred for pacing: a prospective crossover comparison.

His bundle pacing (HBP) and left bundle branch pacing (LBBP) both provide physiologic pacing which maintain left ventricular synchrony. They both improve heart failure (HF) symptoms in atrial fibrillation (AF) patients. We aimed to assess the intra-patient comparison of ventricular function and remodeling as well as leads parameters corresponding to two pacing modalities in AF patients referred for pacing in intermediate term. Uncontrolled tachycardia AF patients with both leads implantation successfully were randomized to either modality. Echocardiographic measurements, New York Heart Association (NYHA) classification, quality-of-life assessments and leads parameters were obtained at baseline and at each 6-month follow up. Left ventricular function including the left ventricular endo-systolic volume (LVESV), left ventricular ejection fraction (LVEF) and right ventricular (RV) function quantified by tricuspid annular plane systolic excursion (TAPSE) were all assessed. Consecutively twenty-eight patients implanted with both HBP and LBBP leads successfully were enrolled (69.1 ± 8.1 years, 53.6% male, LVEF 59.2% ± 13.7%). The LVESV was improved by both pacing modalities in all patients (n = 23) and the LVEF was improved in patients with baseline LVEF at less than 50% (n = 6). The TAPSE was improved by HBP but not LBBP (n = 23). In this crossover comparison between HBP and LBBP, LBBP was found to have an equivalent effect on LV function and remodeling but better and more stable parameters in AF patients with uncontrolled ventricular rates referred for atrioventricular node (AVN) ablation. HBP could be preferred in patients with reduced TAPSE at baseline rather than LBBP.