Is an elevated burden of antiarrhythmic drug (AAD) side-effects the unavoidable price to be traded for a durable suppression of AF relapses in ablated patients? The weaknesses and risks of the AAD suppression algorithm used by current models of AF secondary prevention after catheter ablation

Abstract Background Data on the optimal treatment strategy for antiarrhythmic drug therapy (AAD) after atrial fibrillation (AF) catheter ablation are inconsistent. While AAD potentially stabilizes sinus rhythm, it also increases the patients' treatment burden. Methods Patients from the prospective German Ablation Registry (n=3275) discharged with or without AAD after AF catheter ablation were compared regarding long-term success, cardiovascular events and patient reported outcome. Results In patients with paroxysmal AF (n=2138) recurrence and rehospitalization rates did not differ when discharged with (n=1051) or without (n=1087) AAD (recurrence: adjusted odds ratio (OR) 1.13, 95% confidence interval (CI) [0.95–1.35]; rehospitalization: OR 1.08, 95% CI [0.90–1.30]). The reablation rate was higher and reduced treatment satisfaction was reported more often in those discharged with AAD (reablation: OR 1.30, 95% CI [1.05–1.61]; reduced treatment satisfaction: OR 1.76, 95% CI [1.20–2.58]). Similar rates of recurrences, rehospitalisations, reablations and treatment satisfaction were found in patients with persistent AF (n=1137) discharged with (n=641) or without (n=496) AAD (recurrence: OR 1.22, 95% CI [0.95–1.56]; rehospitalization: OR 1.16, 95% CI [0.90–1.50]; reablation: OR 1.21, 95% CI [0.91–1.61]; treatment satisfaction: OR 1.24, 95% CI [0.74–2.08]). The incidence of cardiovascular events and mortality did not differ at follow-up in paroxysmal and persistent AF patients discharged with or without AAD. Conclusion The rates of recurrences, cardiovascular events and mortality did not differ between patients discharged with or without AAD after AF catheter ablation. However, AAD should be considered carefully in patients with paroxysmal AF, in whom it was associated with a higher reablation rate and reduced treatment satisfaction. FUNDunding Acknowledgement Type of funding sources: None.

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The role of the accessory pathway radiofrequency catheter ablation in the secondary prevention of the malignant tachyarrhythmias in patients with Wolff-Parkinson-White syndrome

Vojnosanitetski pregled ◽

10.2298/vsp1001048m ◽

2010 ◽

Vol 67 (1) ◽

pp. 48-54 ◽

Cited By ~ 3

Author(s):

Nebojsa Mujovic ◽

Miodrag Grujic ◽

Stevan Mrdja ◽

Aleksandar Kocijancic ◽

Tatjana Potpara ◽

...

Keyword(s):

Physical Activity ◽

Atrial Fibrillation ◽

Catheter Ablation ◽

Secondary Prevention ◽

Emotional Stress ◽

Drug Administration ◽

Clinical Manifestation ◽

Accessory Pathway

Background/Aim. The occurrence of atrial fibrillation (AF) in the presence of an accessory pathway (AP) that conducts rapidly is potentially lethal because the rapid ventricular response may lead to ventricular fibrillation (VF). The aim of the study was to determine long-term efficacy of AP catheter-ablation using radiofrequency (RF) current in secondary prevention of VF in WPW patients. Methods. Study included a total of 192 symptomatic WPW patients who underwent RF catheter-ablation of AP in our institution from 1994 to 2007 and were available for clinical follow-up for more than 3 months after procedure. Results. Before ablation, VF was recorded in total of 27 patients (14.1%). In 14 of patients (51.9%) VF was the first clinical manifestation of WPW syndrome. A total of 35 VF episodes were identified in 27 patients. The occurrence of VF was preceded by physical activity or emotional stress in 17.1% of cases, by alcohol abuse in 2.9% and by inappropriate intravenous drug administration in 28.6%. In addition, no clear precipitating factor was identified in 40% of VF cases, while informations about activities preceding 11.4% of VF episodes were not available. The follow-up of 5.7 ? 3.3 years was obtained in all of 27 VF patients. Of the 20 patients who underwent successful AP ablation, all were alive, without syncope or ventricular tachyarrhythmias during long-term follow-up. In 4 of 7 unsuccessfully treated patients, recurrence of supraventricular tachycardia and/or preexcited atrial fibrillation were recorded; one of these patients suddenly died of VF, 6 years after procedure. Conclusion. In significant proportion of WPW patients, VF was the first clinical manifestation of WPW syndrome, often precipitated by physical activity, emotional stress or inappropriate drug administration. Successful elimination of AP by percutaneous RF catheter-ablation is highly effective in secondary prevention of life-threatening tachyarrhythmias in patients with ventricular preexcitation.

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Catheter Ablation versus Antiarrhythmic Drug Therapy for Atrial Fibrillation (CABANA) Trial: Study Rationale and Design

American Heart Journal ◽

10.1016/j.ahj.2018.02.015 ◽

2018 ◽

Vol 199 ◽

pp. 192-199 ◽

Cited By ~ 63

Author(s):

Douglas L. Packer ◽

Daniel B. Mark ◽

Richard A Robb ◽

Kristi H. Monahan ◽

Tristram D. Bahnson ◽

...

Keyword(s):

Atrial Fibrillation ◽

Drug Therapy ◽

Catheter Ablation ◽

Antiarrhythmic Drug ◽

Antiarrhythmic Drug Therapy

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Development of atrial fibrillation catheter ablation and ablation strategies

ESC CardioMed ◽

10.1093/med/9780198784906.003.0509 ◽

2018 ◽

pp. 2168-2173

Author(s):

Gerhard Hindricks ◽

Nikolaos Dagres ◽

Philipp Sommer ◽

Andreas Bollmann

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Antiarrhythmic Drug ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

First Line ◽

Ventricular Ejection Fraction ◽

First Line Therapy

Catheter ablation has evolved to an established therapy for patients with symptomatic atrial fibrillation (AF). Complete pulmonary vein isolation currently is the best endpoint for catheter ablation. This can be achieved with balloon-based cryoablation as well as by point-by-point radiofrequency ablation supported by non-fluoroscopic mapping technologies—both technologies seem equally effective. AF catheter ablation is indicated in patients with symptomatic AF usually after failure of antiarrhythmic drug therapy. Selected patients with AF and tachycardia-induced heart failure may benefit from ablation by a significant improvement of left ventricular ejection fraction. The success rate (i.e. freedom from AF and atrial tachycardia) after a single procedure is approximately 50–60% for patients with paroxysmal AF and 40% for patients with persistent AF. With multiple procedures, freedom from AF can be achieved in up to 80% of patients with paroxysmal AF and 60% of patients with persistent AF. When performed after failed rhythm control attempts with antiarrhythmic drugs, catheter ablation is superior to a further attempt with antiarrhythmic drug medication. When applied as first-line therapy, catheter ablation tends to be slightly superior to first-line antiarrhythmic drug treatment. The complication rate of AF catheter ablation is 5–7%; severe complications occur in 2–3% (cardiac tamponade, periprocedural stroke, atrio-oesophageal fistula). Catheter ablation significantly improves quality of life but has no proven effect on mortality and/or stroke. Thus, in general, oral anticoagulation should be continued long term even if ablation is considered successful.

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Sotalol hydrochloride (Betapace): a new antiarrhythmic drug

American Journal of Critical Care ◽

10.4037/ajcc1993.2.5.397 ◽

1993 ◽

Vol 2 (5) ◽

pp. 397-406

Author(s):

CS Dunnington

Keyword(s):

Side Effects ◽

Antiarrhythmic Drug ◽

Action Potential Duration ◽

Antihypertensive Agent ◽

Left Ventricular ◽

Monophasic Action Potential ◽

Class Iii ◽

Cardiac Tissues ◽

Supraventricular Tachyarrhythmias ◽

Low Incidence

Sotalol hydrochloride (Betapace), recently released by the Food and Drug Administration for general use, is used to treat a variety of ventricular and supraventricular tachyarrhythmias. The drug's dominant action is the result of combined nonselective beta-adrenergic antagonism (Class II effect) and monophasic action potential duration prolongation in all cardiac tissues (Class III effect). It causes less left ventricular depression than propranolol and has a low incidence of toxicity. It is a useful addition to the antiarrhythmic drug armamentarium. This article reviews the drug's pharmacokinetic, pharmacodynamic and electrophysiologic properties, clinical uses and potential side effects. Reports on the drug's use as an antianginal and antihypertensive agent are also discussed.

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Preventive Ventricular Tachycardia Ablation in Patients with Ischaemic Cardiomyopathy: Meta-analysis of Randomised Trials

Arrhythmia & Electrophysiology Review ◽

10.15420/aer.2019.31.3 ◽

2019 ◽

Vol 8 (3) ◽

pp. 173-179 ◽

Cited By ~ 4

Author(s):

Roland R Tilz ◽

Charlotte Eitel ◽

Evgeny Lyan ◽

Kivanc Yalin ◽

Spyridon Liosis ◽

...

Keyword(s):

Ventricular Tachycardia ◽

Catheter Ablation ◽

Secondary Prevention ◽

Meta Analysis ◽

Randomised Trials ◽

Icd Implantation ◽

Icd Therapy ◽

Number Of Patients ◽

Significant Difference ◽

Vt Ablation

Catheter ablation of ventricular tachycardia (VT) aims to treat the underlying arrhythmia substrate to prevent ICD therapies. The aim of this meta-analysis was to assess the safety and efficacy of VT ablation prior to or at the time of secondary prevention ICD implantation in patients with coronary artery disease, as compared with deferred VT ablation. Based on a systematic literature search, three randomised trials were considered eligible for inclusion in this analysis, and data on the number of patients with appropriate ICD shocks, appropriate ICD therapy, arrhythmic storm, death and major complications were extracted from each study. On pooled analysis, there was a significant reduction of appropriate ICD shocks (OR 2.58; 95% CI [1.54–4.34]; p<0.001) and appropriate ICD therapies (OR 2.04; 95% CI [1.15–3.61]; p=0.015) in patients undergoing VT ablation at the time of ICD implantation without significant differences with respect to complications (OR 1.39; 95% CI [0.43–4.51]; p=0.581). Mortality did not differ between both groups (OR 1.30; 95% CI [0.60–2.45]; p=0.422). Preventive catheter ablation of VT in patients with coronary heart disease at the time of secondary prevention ICD implantation results in a significant reduction of appropriate ICD shocks and any appropriate ICD therapy compared with patients without or with deferred VT ablation. No significant difference with respect to complications or mortality was observed between both treatment strategies.

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