Atrioventricular Nodal Ablation in Atrial Fibrillation

Abstract

Background-In the treatment of patients with refractory atrial fibrillation (AF), the safety and efficacy of atrioventricular nodal ablation (AVNA) versus pharmacotherapy alone remains unclear. Additionally, the impact of AVNA in patients with reduced systolic function is of growing interest. Methods and Results-A total of 5 randomized or prospective trials were included for efficacy review (314 patients), 11 studies for effectiveness review (810 patients), and 47 studies for safety review (5632 patients). All-cause mortality was similar between AVNA and medical therapy (3.1% versus 3.3%; relative risk ratio, 1.05; 95% confidence interval [CI], 0.29 -3.85). There was no significant difference in exercise duration or ejection fraction (EF) with AVNA relative to pharmacotherapy. In subgroup analysis, patients with baseline systolic dysfunction (116 patients; mean EF, 44%) showed significant relative improvement in EF after AVNA (ϩ4% greater; 95% CI, 3.11-4.89). In pooled observational analysis, AVNA was also associated with significant improvement in EF only in patients with systolic dysfunction (ϩ7.44%; 95% CI, 5.4 -9.5). The incidence of procedure-related mortality (0.27%) and malignant arrhythmia (0.57%) was low. At mean follow-up of 26.5 months, the incidence of sudden cardiac death after AVNA was 2.1%. There was significant heterogeneity in quality-of-life scales used; compared with pharmacotherapy, AVNA was associated with significant improvement in several symptoms (palpitations, dyspnea). Conclusions-In the management of refractory AF, AVNA is associated with improvement in symptoms and quality of life, with a low incidence of procedure morbidity. In patients with reduced systolic function, AVNA demonstrates small but significantly improved echocardiographic outcomes relative to medical therapy alone. (Circ Arrhythm Electrophysiol. 2012;5:68-76.)

2016 ESC Guidelines for the Management of Atrial Fibrillation Developed in Collaboration With EACTS

“…It is a relatively simple procedure with a low complication rate and low long-term mortality risk, 563,564 especially when the pacemaker is implanted a few weeks before the AV nodal ablation and the initial pacing rate after ablation is set at 70-90 b.p.m. 565, 566 The procedure does not worsen LV function 567 and may even improve LVEF in selected patients. 568 -570 In selected…”

Management of Atrial Fibrillation in Critically Ill Patients

“…An elective cardioversion is generally recommended for patients with a recent onset AF as well as in patients who remain symptomatic despite optimal rate control. After discharge from the ICU selected patients may benefit from catheter-based pulmonary vein isolation [38, 39, 41, 103], surgical treatment of AF (Cox Maze III procedure) [104], or AV node ablation with permanent (biventricular) pacing [105, 106] to reduce symptoms and increase functional performance. A multidisciplinary approach in those cases is necessary.…”

2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS

“…Zabieg ten nie pogarsza czynności lewej komory [567], a nawet może poprawiać LVEF u wybranych pacjentów [568][569][570]. U wybranych pacjentów z HFrEF, u których zastosuje się stymulację dwukomorową (terapię resynchronizującą), AF może ustąpić [571], choć ten efekt "kontroli rytmu" terapii renchronizującej jest prawdopodobnie mały i z pewnością wymaga potwierdzenia [572].…”