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Restoring normal sinus rhythm in atrial fibrillation: Evidence from pharmacologic therapy and catheter ablation trials

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Abstract

Although clinical evidence indicates that many of the electrophysiologic and functional changes associated with atrial fibrillation (AF) can be reversed by maintaining normal sinus rhythm (NSR), a series of large-scale randomized trials failed to demonstrate that this strategy provides a survival advantage. These studies have methodologic limitations, however, that restrict their applicability to the entire AF population. Invasive techniques, including percutaneous catheter ablation and the surgical Maze procedure, offer the potential to reduce the frequency of and in some cases cure AF, although there are serious associated risks. The development and refinement of these techniques have improved outcomes, and they now represent a viable early option for select AF patients. In light of its manifest benefits, the restoration and maintenance of NSR through pharmacologic or nonpharmacologic treatment should remain the therapeutic objective for many AF patients.

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References and Recommended Reading

  1. Hohnloser S, Kuck KH, Lilienthal J, for the PIAF Investigators: Rhythm or rate control in atrial fibrillation— pharmacological intervention in atrial fibrillation (PIAF): a randomised trial. Lancet 2000, 356:1789–1794.

    Article  PubMed  CAS  Google Scholar 

  2. Carlsson J, Miketic S, Windeler J, et al.: Randomized trial of rate-control versus rhythm-control in persistent atrial fibrillation: the Strategies of Treatment of Atrial Fibrillation (STAF) study. J Am Coll Cardiol 2003, 41:1690–1696.

    Article  PubMed  Google Scholar 

  3. Van Gelder IC, Hagens VE, Bosker HA, et al.: for the Rate Control Versus Electrical Cardioversion for Resistant Atrial Fibrillation Study Group: A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. N Engl J Med 2002, 347:1834–1840.

    Article  PubMed  Google Scholar 

  4. The AFFIRM Investigators: A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med 2002, 347:1825–1833.

    Article  Google Scholar 

  5. Opolski G, Torbicki A, Kosior DA, et al.: Rate control vs rhythm control in patients with nonvalvular persistent atrial fibrillation: the results of the Polish How to Treat Chronic Atrial Fibrillation (HOT CAFE) study. Chest 2004, 126:476–486.

    Article  PubMed  Google Scholar 

  6. Falk RH: Management of atrial fibrillation - radical reform or modest modification? N Engl J Med 2002, 347:1883–1884.

    Article  PubMed  Google Scholar 

  7. Curtis AB, Gersh BJ, Shemanski L, for the AFFIRM Executive Committee and AFFIRM Investigators: Survival in patients with atrial fibrillation with and without congestive heart failure treated with a rate control or a rhythm control strategy: results from the AFFIRM trial [abstract 183]. Pacing Clin Electrophysiol 2003, 26:974.

    Google Scholar 

  8. Pappone C, Oreto G, Rosanio S, et al.: Atrial electroanatomic remodeling after circumferential radiofrequency pulmonary vein ablation: efficacy of an anatomic approach in a large cohort of patients with atrial fibrillation. Circulation 2001, 104:2539–2544.

    PubMed  CAS  Google Scholar 

  9. Oral H, Knight BP, Tada H, et al.: Pulmonary vein isolation for paroxysmal and persistent atrial fibrillation. Circulation 2002, 105:1077–1081.

    Article  PubMed  Google Scholar 

  10. Hsu LF, Ja⫬ P, Sanders P, et al.: Catheter ablation for atrial fibrillation in congestive heart failure. N Engl J Med 2004, 351:2373–2383. Established the efficacy of PVI in patients with structural heart disease and CHF.

    Article  PubMed  CAS  Google Scholar 

  11. Cox JL, Boineau JP, Schuessler RB, et al.: Successful surgical treatment of atrial fibrillation. Review and clinical update. JAMA 1991, 266:1976–1980.

    Article  PubMed  CAS  Google Scholar 

  12. Haissaguerre M, Jais P, Shah DC, et al.: Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med 1998, 339:659–666.

    Article  PubMed  CAS  Google Scholar 

  13. Markides V, Schilling RJ: Atrial fibrillation: classification, pathophysiology, mechanisms and drug treatment. Heart 2003, 89:939–943.

    Article  PubMed  Google Scholar 

  14. Wijffels MC, Kirchhof CJ, Dorland R, Allessie MA:Atrial fibrillation begets atrial fibrillation. A study in awake chronically instrumented goats. Circulation 1995, 92:1954–1968.

    PubMed  CAS  Google Scholar 

  15. Hobbs WJC, Fynn S, Todd DM, et al.: Reversal of atrial electrical remodeling after cardioversion of persistent atrial fibrillation in humans. Circulation 2000, 101:1145–1151.

    PubMed  CAS  Google Scholar 

  16. Borggrefe M, Breithardt G: Maintenance of sinus rhythm as a therapy goal. Europace Supplements 2000, I-SuppC:C1-C5.

    Google Scholar 

  17. Hagens VE, Van Veldhuisen DJ, Kamp O, et al.: Effect of rate and rhythm control on left ventricular function and cardiac dimensions in patients with persistent atrial fibrillation: results from the RAte Control versus Electrical cardioversion for persistent atrial fibrillation (RACE) study. Heart Rhythm 2005, 2:19–24.

    Article  PubMed  Google Scholar 

  18. Gosselink AT, Crijns HJ, Hamer HP, et al.: Changes in left and right atrial size after cardioversion of atrial fibrillation: role of mitral valve disease. J Am Coll Cardiol 1993, 22:1666–1672.

    Article  PubMed  CAS  Google Scholar 

  19. Manning WJ, Silverman DI, Katz SE, et al.: Impaired left atrial mechanical function after cardioversion: relation to the duration of atrial fibrillation. J Am Coll Cardiol 1994, 23:1535–1540.

    Article  PubMed  CAS  Google Scholar 

  20. The AFFIRM Investigators: Relationships between sinus rhythm, treatment, and survival in the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Study. Circulation 2004, 109:1509–1513.

    Article  Google Scholar 

  21. Fuster V, Rydén LE, Asinger RW, et al.: ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: executive summary. Circulation 2001, 104:2118–2150.

    PubMed  CAS  Google Scholar 

  22. Clark DM, Plumb VJ, Epstein AE, et al.: Hemodynamic effects of an irregular sequence of ventricular cycle lengths during atrial fibrillation. J Am Coll Cardiol 1997, 30:1039–1045.

    Article  PubMed  CAS  Google Scholar 

  23. Morillo CA, Klein GJ, Jones DL, Guiraudon CM: Chronic rapid atrial pacing. Structural, functional, and electrophysiological characteristics of a new model of sustained atrial fibrillation. Circulation 1995, 91:1588–1595.

    PubMed  CAS  Google Scholar 

  24. Packer DL, Bardy GH, Worley SJ, et al.: Tachycardia- induced cardiomyopathy: a reversible form of left ventricular dysfunction. Am J Cardiol 1986, 57:563–570.

    Article  PubMed  CAS  Google Scholar 

  25. Upshaw CB: Hemodynamic changes after cardioversion of chronic atrial fibrillation. Arch Intern Med 1997, 157:1070–1076.

    Article  PubMed  Google Scholar 

  26. Shinbane JS, Wood MA, Jensen DN, et al.: Tachycardiainduced cardiomyopathy: a review of animal models and clinical studies. J Am Coll Cardiol 1997, 29:709–715.

    Article  PubMed  CAS  Google Scholar 

  27. Reynolds MR, Mahoney EM, Buxton AE, et al.: Influence of age and gender on symptoms and quality of life in atrial fibrillation [abstract 103]. Heart Rhythm 2004, 1-Suppl:S33-S34.

    Article  Google Scholar 

  28. Hagens VE, Ranchor AV, Van Sonderen E, et al.: Effect of rate or rhythm control on quality of life in persistent atrial fibrillation. J Am Coll Cardiol 2004, 43:241–247.

    Article  PubMed  Google Scholar 

  29. Singh BN, Singh SN, Reda DJ, et al.: Amiodarone versus sotalol for atrial fibrillation. N Engl J Med 2005, 352:1861–1872. A well-performed randomized study confirming the superiority of amiodarone compared with other antiarrhythmic drugs for the maintenance of sinus rhythm. Demonstrated improved quality of life and functional capacity associated with the pharmacologic maintenance of sinus rhythm.

    Article  PubMed  CAS  Google Scholar 

  30. Coyne K, Margolis MK, Grandy S, Zimetbaum P: The state of patient-reported outcomes in atrial fibrillation—a review of current measures. Pharmacoeconomics 2005, 23:687–708.

    Article  PubMed  Google Scholar 

  31. Zimetbaum P: An argument for maintenance of sinus rhythm in patients with atrial fibrillation. Circulation 2005, 111:1350–1357. A review of the clinical trials of rate versus rhythm control.

    Article  Google Scholar 

  32. Crijns HJGM: Rate versus rhythm control in patients with atrial fibrillation: what the trials really say. Drugs 2005, 65:1651–1667.

    Article  PubMed  CAS  Google Scholar 

  33. Hoekstra EH: Importance of side effects of antiarrhythmic drugs to failure of rhythm control in RACE study [abstract P2751]. Eur Heart J 2003, 24(Suppl):514.

    Article  Google Scholar 

  34. Hagens VE, Crijns HJGM, Van Veldhuisen DJ, et al.: Rate control versus rhythm control for patients with persistent atrial fibrillation with mild to moderate heart failure: results from the RAte Control versus Electrical cardioversion (RACE) study. Am Heart J 2005, 149:1106–1111.

    Article  PubMed  Google Scholar 

  35. Pedersen OD, Bagger H, Keller N, et al.: Efficacy of dofetilide in the treatment of atrial fibrillation-flutter in patients with reduced left ventricular function: a Danish investigations of arrhythmia and mortality on dofetilide (DIAMOND) substudy. Circulation 2001, 104:292–296.

    PubMed  CAS  Google Scholar 

  36. Deedwania PC, Singh BN, Ellenbogen K, et al.: for the Department of Veterans Affairs CHF-STAT Investigators: Spontaneous conversion and maintenance of sinus rhythm by amiodarone in patients with heart failure and atrial fibrillation: observations from the Veterans Affairs Congestive Heart Failure Survival Trial of Antiarrhythmic Therapy (CHF-STAT). Circulation 1998, 98:2574–2579.

    PubMed  CAS  Google Scholar 

  37. Saltman AE, Rosenthal LS, Francalancia NA, Lahey SJ:A completely endoscopic approach to microwave ablation for atrial fibrillation. Heart Surg Forum 2003 6:E38-E41.

    PubMed  Google Scholar 

  38. Thomas L, Boyd A, Thomas SP, et al.: Atrial structural remodelling and restoration of atrial contraction after linear ablation for atrial fibrillation. Eur Heart J 2003, 24:1942–1951.

    Article  PubMed  Google Scholar 

  39. Pappone C, Rosario S, Augello G, et al.: Mortality, morbidity, and quality of life after circumferential pulmonary vein ablation for atrial fibrillation. J Am Coll Cardiol 2003, 42:185–197.

    Article  PubMed  Google Scholar 

  40. Wazni OM, Marrouche NF, Martin DO, et al.: Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of symptomatic atrial fibrillation. JAMA 2005, 293:2634–2640.

    Article  PubMed  CAS  Google Scholar 

  41. Marrouche NF, Dresing T, Cole C, et al.: Circular mapping and ablation of the pulmonary vein for treatment of atrial fibrillation. Impact of different catheter technologies. J Am Coll Cardiol 2002, 40:464–474.

    Article  PubMed  Google Scholar 

  42. Keane D, Mansour M, Singh J: Detection by intracardiac echocardiography of early formation of left atrial thrombus during pulmonary vein isolation. Europace 2004, 6:109–110.

    Article  PubMed  Google Scholar 

  43. Schwab JO, Burkhardt D, Yang A, et al.: ECG signs mimicking acute inferior wall myocardial infarction are associated with elevated myocardial enzymes during isolation of pulmonary vein for focal atrial fibrillation. Europace 2004, 6:111–115.

    Article  PubMed  Google Scholar 

  44. Pappone C, Oral H, Santinelli V, et al.: Atrio-esophageal fistula as a complication of percutaneous transcatheter ablation of atrial fibrillation. Circulation 2004, 109:2724 -2726. Reports atrial-esophageal fistual formation as a potentially lifethreatening complication of PVI.

    Article  PubMed  Google Scholar 

  45. Reddy VY, Malchano ZJ, Neuzil P, et al.: Early clinical experience with CARTO-Merge for integration of 3D-CT imaging with real-time mapping to guide catheter ablation of atrial fibrillation [abstract P2-81]. Heart Rhythm 2005, 2(Suppl 1):S160.

    Article  Google Scholar 

  46. Pachon M JC, Pachon M EI, Pachon M JC, et al.: A new treatment for atrial fibrillation based on spectral analysis to guide the catheter RF-ablation. Europace 2004; 6:590–601.

    Article  PubMed  Google Scholar 

  47. Geidel S, Lass M, Boczor S, et al.: Monopolar and bipolar radiofrequency ablation surgery: 3-year experience in 90 patients with permanent atrial fibrillation. Heart Surg Forum 2004, 7:404–408.

    Google Scholar 

  48. Senatore G, Stabile G, Bertaglia E, et al.: Role of transtelephonic electrocardiographic monitoring in detecting short-term arrhythmia recurrences after radiofrequency ablation in patients with atrial fibrillation. J Am Coll Cardiol 2005, 45:873–876. Demonstrates the frequency of asymptomatic recurrence of AF following PVI. Highlights the need for thorough monitoring and continuation of anticoagulation in patients with indications for warfarin irrespective of treatments used to maintain sinus rhythm.

    Article  PubMed  Google Scholar 

  49. Bertaglia E: CACAF: Catheter Ablation for the Cure of Atrial Fibrillation study. Presented at the 54th Annual Scientific Session of the American College of Cardiology. Orlando, FL; March 6-9, 2005.

  50. Oral H, Knight BP, Ozydin M, et al.: Clinical significance of early recurrences of atrial fibrillation after pulmonary vein isolation. J Am Coll Cardiol 2002, 40:100–104.

    Article  PubMed  Google Scholar 

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  1. Department of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, 02215, Boston, MA, USA

    Peter Zimetbaum MD

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Zimetbaum, P. Restoring normal sinus rhythm in atrial fibrillation: Evidence from pharmacologic therapy and catheter ablation trials. Curr Cardiol Rep 8, 377–386 (2006). https://doi.org/10.1007/s11886-006-0078-y

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