A randomized controlled trial of catheter ablation versus medical treatment of atrial fibrillation in heart failure (the CAMTAF trial).

BACKGROUND: Restoring sinus rhythm in patients with heart failure (HF) and atrial fibrillation (AF) may improve left ventricular (LV) function and HF symptoms. We sought to compare the effect of a catheter ablation strategy with that of a medical rate control strategy in patients with persistent AF and HF. METHODS AND RESULTS: Patients with persistent AF, symptomatic HF, and LV ejection fraction <50% were randomized to catheter ablation or medical rate control. The primary end-point was the difference between groups in LV ejection fraction at 6 months. Baseline LV ejection fraction was 32±8% in the ablation group and 34±12% in the medical group. Twenty-six patients underwent catheter ablation, and 24 patients were rate controlled. Freedom from AF was achieved in 21/26 (81%) at 6 months off antiarrhythmic drugs. LV ejection fraction at 6 months in the ablation group was 40±12% compared with 31±13% in the rate control group (P=0.015). Ablation was associated with better peak oxygen consumption (22±6 versus 18±6 mL/kg per minute; P=0.014) and Minnesota living with HF questionnaire score (24±22 versus 47±22; P=0.001) compared with rate control. CONCLUSIONS: Catheter ablation is effective in restoring sinus rhythm in selected patients with persistent AF and HF, and can improve LV function, functional capacity, and HF symptoms compared with rate control. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT01411371.

Does ventricular dyssynchrony on echocardiography predict response to cardiac resynchronisation therapy? A randomised controlled study.

OBJECTIVE: To determine the value of echocardiography in predicting response to cardiac resynchronisation therapy (CRT). METHODS: This is a prospective randomised study that recruited patients with (group 1) and without (group 2) echocardiographic evidence of mechanical dyssynchrony. 73 heart failure patients (NYHA III-IV) with a requirement for an implantable cardioverter defibrillator, QRS ≥120 ms and LV ejection fraction (EF) <35% were studied. Group 1 patients received CRT-D (26 patients). Group 2 patients were randomised to CRT-D (group 2a: 23 patients) or implantable cardioverter defibrillator (group 2b: 21 patients). MAIN OUTCOME MEASURES: were peak oxygen consumption (VO(2)max), NYHA class, and echocardiography at baseline and at 6 months. RESULTS: 62% of group 1 patients achieved ≥1 ml/kg/min increase in VO(2)max at 6 months versus 50% in group 2a and 21% in group 2b (p=0.04). Group 1 patients showed significant improvements in VO(2)max (15.8±2 to 18.0±4 ml/kg/min, p=0.01), NYHA class (3.1±0.3 to 1.9±0.7, p<0.001) and EF (22±7% to 26±9%, p=0.02). Group 2a showed significant improvement in NYHA class (3.1±0.3 to 2.2±0.7, p<0.001) but no change in EF or VO(2)max. Group 2b showed no change in NYHA class or EF with a decline in VO(2)max (16.4±4 to 14.1±4, p=0.03). A significantly higher proportion of patients in group 2b showed ≥1 ml/kg/min deterioration in VO(2)max compared to group 2a (68% vs 23%, HR for group 2b: 2.4, 95% CI 1.2 to 4.8, p=0.005). CONCLUSIONS: The presence of echocardiographic dyssynchrony identifies patients who derive the most improvement from CRT. Patients without dyssynchrony also show more benefit and less deterioration with CRT than without and should not be denied CRT.

A prospective comparison of echocardiography and device algorithms for atrioventricular and interventricular interval optimization in cardiac resynchronization therapy.

AIMS: Echocardiographic optimization of atrioventricular (AV) and interventricular (VV) intervals in cardiac resynchronization therapy (CRT) is costly, time-consuming, and requires skill and expertise so is usually undertaken only in 'non-responder' patients. An algorithm in St Jude Medical CRT devices (QuickOpt) claims to optimize these settings automatically. The aim of this study was to compare the two optimization techniques. METHODS AND RESULTS: Optimization of AV and VV intervals was performed a month after CRT device implantation in 26 patients with heart failure, first by echocardiography then by QuickOpt. The left ventricular outflow tract (LVOT) velocity-time integral (VTI) was measured after optimization by each method. Agreement between the optimization methods was assessed by the Bland-Altman analysis and correlation by Pearson's correlation coefficient. There was good correlation between the LVOT VTI following optimization by both methods (R2 = 0.77, P < 0.001). However, agreement between the two methods was poor, with 15 of 26 and 10 of 26 patients having a >20 ms difference in the optimal AV and VV interval values, respectively. Left ventricular outflow tract VTI was significantly better (22 of 26 patients; P < 0.001) in patients optimized by echocardiography than by QuickOpt. CONCLUSION: There is a poor agreement in optimal AV and VV intervals determined by echocardiography and QuickOpt, with echocardiographic optimization giving a superior haemodynamic outcome.

Percutaneous permanent pacemaker implantation via the azygous vein in a patient with superior vena cava occlusion.

Occlusion of the superior vena cava (SVCO) makes implantation of permanent pacemakers challenging and difficult. We describe an extended application of a Medtronic Attain (Medtronic Inc., Minneapolis, MN, USA) guide catheter (a tool designed for delivery of left ventricular pacing leads into the coronary sinus) for delivery of a right ventricular pacing lead via the azygous vein in a 72-year-old woman with SVCO secondary to long-term central venous hemodialysis catheters. This approach allowed the use of an endocardial pacing lead, implantation under local anesthesia, and conventional positioning of the pacemaker generator in the pectoral region in a patient with SVCO.