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.) 2008 Massachusetts Medical
Society
Credits: Tsai CT; Lai LP; Hwang JJ; Wang YC; Chiang FT; Lin JL