From the Department of Cardiology and Arrhythmologic Center, Ospedali
Riuniti, Lavagna (M.B., L.G.); the Department of Cardiology and Arrhythmologic
Center, Ospedale S Maria Nuova, Reggio Emilia (C.M., N.B., G.L.); and the
Section of Arrhythmology, Ospedale Civile, Imperia (G.M., R.M.).
Correspondence to Michele Brignole, MD, Via A Grilli 164, 16041 Borzonasca (GE), Italy. E-mail brignole{at}omninet.it
Methods and Results—We performed a multicenter, controlled,
randomized, 12-month evaluation of the clinical effects of
atrioventricular junction ablation and VVIR pacemaker
(Abl+Pm) versus pharmacological (drug) treatment in 66 patients with
chronic (lasting >6 months) AF who had clinically manifest heart
failure and heart rate >90 bpm on 3 standard ECGs recorded at rest
during stable clinical conditions on different days. Before
completion of the study, withdrawals occurred in 8 patients
of the drug group and in 4 patients of the Abl+Pm group. At the end of
the 12 months, the 28 Abl+Pm patients who completed the study showed
lower scores in palpitations (-78%; P=0.000) and
effort dyspnea (-22%; P=0.05) than the 26 of the drug
group. Lower scores, although not significant, were also observed for
exercise intolerance (-20%), easy fatigue (-17%), chest discomfort
(-50%), Living with Heart Failure Questionnaire (-14%), New York
Heart Association functional classification (-4%), and Activity scale
(-12%). The intrapatient comparison between enrollment and month 12
showed that in the Abl+Pm group, all variables except easy fatigue
improved significantly from 14% to 82%. However, because an
improvement was also observed in the drug group, the difference between
the 2 groups was significant only for palpitations
(P=0.000), effort dyspnea (P=0.01),
exercise intolerance (P=0.005), easy fatigue
(P=0.02), and chest discomfort (P=0.02).
Cardiac performance, evaluated by means of standard
echocardiogram and exercise test, did not differ significantly between
the 2 groups and remained stable over time.
Conclusions—In patients with heart failure and chronic AF, Abl+Pm
treatment is effective and superior to drug therapy in controlling
symptoms, although its efficacy appears to be less than that observed
in uncontrolled studies because some improvement can also be expected
in medically treated patients. Cardiac performance is not
modified by the treatment.
Assignment and Blinding
Patients were recruited from September 1993 to June 1996 among subjects
referred to our institutions from the emergency room, inpatient
service, and outpatient arrhythmia clinic. The study was
terminated in July 1997.
Inclusion Criteria
Exclusion Criteria
End Points
Secondary end points were intrapatient comparison of quality of life
and specific symptoms between enrollment and month 12;
recording of major clinical events occurring during the
12-month study period, for example, death and major morbidities,
complications of the treatment, and number of hospitalizations; and
objective assessment of cardiac performance at the beginning
and end of the study.
Outcome Measurements
Quality-of-Life Questionnaire
Specific Symptoms Scale
New York Heart Association Classification
Specific Activity Scale
Ablation Procedure and Pacemaker Implantation
Follow-up
Patients were seen at the outpatient clinic every 3 months for 12
months. The follow-up visit included the gathering of data on clinical
status, symptoms, drug treatments, and side effects. Moreover, on
enrollment and at the 12-month visit, the patients underwent 24-hour
Holter recording, echocardiography, and
exercise stress testing.
Statistics
Comparison between continuous variables was obtained by paired and
unpaired Student's t test, as appropriate; comparison
between proportions was obtained by Fisher's exact
test.
In all 32 patients assigned to the Abl+Pm arm, the ablation end point
(production of complete, persistent AV block) was reached
without complications, with a median of 2 burns (range 1 to 31) at 30
to 40 W. Right-sided ablation was successful in 27 patients and a
sequential approach (right- and left-sided ablation) in the other 5. In
3 patients, AV conduction resumed after a few days, and a second
procedure was rapidly performed that achieved persistent AV block. Four
patients assigned to the drug arm did not complete the study period
because of the occurrence of severe symptoms and received ablation and
pacemaker treatment after 1, 1, 4, and 6 months.
Analysis
Secondary End Points
Clinical events occurring during the study period are reported in Table 3
Cardiac performance, evaluated by means of standard
echocardiography and exercise testing, did not
differ significantly between the 2 groups and remained stable over time
(Table 4
As a consequence of the pacemaker, on the month-12 Holter
recording, minimum and mean heart rate were higher and maximum
heart rate was lower in the Abl+Pm group (Table 4
Secondary Ablation and Pacemaker Treatment
The main result of this study is that Abl+Pm treatment was effective
and superior to drug therapy in controlling specific symptoms, although
its efficacy was lower than that observed in the intrapatient
comparison, as some improvement was also observed in the medically
treated patients. Improvement was greater for the specific symptoms of
the disease than for the indexes of health-related quality of life,
namely LHFQ, NYHA, and activity scale, which failed to prove a
statistically significant benefit. Whether this finding was due to a
low sensitivity of these outcome measurements is open to question.
However, the absolute decrease of 11 points in LHFQ score observed in
the present study in the Abl+Pm group was slightly superior to the
5- to 8-point decrease observed with new inotropic agents in patients
with severe heart failure10 11 but
inferior to the 30-point decrease observed in patients with
paroxysmal AF treated with ablation and pacemaker
treatment.8 Given the lack of correlation between
change in functional status and improvement in cardiac
performance (evaluated by means of
echocardiographic and exercise indexes), which remained
stable during follow-up, one could suppose that the treatment had a
greater effect on those symptoms more directly linked to rapid and
irregular rhythm than on the outcome of the underlying heart
disease.15 This is supported by the slight (not
significant) reduction in adverse clinical events observed in the
Abl+Pm group during the study period.
Ablation and pacing treatment is relatively simple to perform, elicits
no complications, is safe, and does not cause impairment of cardiac
performance, serious adverse effects, or increased risk of
death in the 12 months after ablation.
Comparison With Previous Uncontrolled Studies
Several previous studies have suggested that ablation and pacemaker
treatment may cause an improvement in cardiac performance as a
consequence of rhythm regularization and better rate control. A
prospective hemodynamic study16
showed a significant increase in cardiac output from 1.9 to 2.3
L/m2 (6 months after ablation). In a controlled
study involving patients in whom the ventricular rate was
believed to be well controlled (but irregular), Daoud et
al19 found that an increase in cardiac output
could be achieved by regularization of the rhythm. The negative
hemodynamic consequences of irregular sequences of R-R
intervals during AF has been found to be independent of heart
rate.20 In case report studies, the reversal of
tachyarrhythmia-induced
cardiomyopathy has been observed after
ablation21 as well as after control of heart rate
by means of medical therapy.22 23 24
Echocardiographic left ventricular
diameters have been shown to decrease, especially in patients with
baseline depressed function, thus leading to improvements in the
indexes of systolic function, namely ejection fraction and
fractional shortening.3 4 5 17 25 26 27 Exercise
capacity has also been seen to improve after
ablation.5 27 28 Contrary to these studies, we
were unable to show significant modifications of
echocardiographic parameters and exercise
stress testing either in intergroup or intrapatient comparisons. Even
though in patients with depressed left ventricular function
we observed a slight increase in the value of the ejection fraction
after 12 months, this increase was also observed in the control group,
thus making it unlikely that it was due to a beneficial effect of
ablation, as supposed in many uncontrolled
studies.3 5 17 25 26 The lack of improvement in
exercise capacity was also observed in the Ellenbogen
study.17 The reason for these differences is
unclear. Admittedly, our study did not have the power to show slight
differences, if any, in cardiac performance, and we recognize
the limitations inherent in the method of assessment of cardiac
performance. Indeed, comparing
echocardiographic data from several different
investigators and between different underlying rhythms and the
heterogeneous pathogenesis of the population might have
generated confounding results. Furthermore, the low maximal heart rate
achieved during stress testing in the Abl+Pm group may have contributed
to lower stress tolerance in that population. Moreover, the mean heart
rate of our population, evaluated by means of Holter monitoring, was
not particularly high and might have been lower than that observed in
other studies. On the other hand, the beneficial
hemodynamic effect of regularization and rhythm control
might have been counteracted by the deleterious effect of asynergic
ventricular contraction caused by right apical
ventricular pacing.29 30
No case of overt reversal of cardiac dysfunction was observed,
suggesting that tachycardia-induced
cardiomyopathy is rare in an unselected population
of elderly patients with a ventricular rate not
particularly elevated and known cause of heart disease. Indeed,
tachycardia-induced cardiomyopathy
seems to be more likely in patients without evidence of known heart
disease and with a very high ventricular
rate.21 22 23 24 On the other hand, fortunately, we
did not observe any case of severe hemodynamic
deterioration caused by severe mitral regurgitation, as
occurred after ablation in the population of Vanderheyden et
al.31 One explanation could be that we excluded
from enrollment the patients with end-stage heart failure and those in
NYHA functional class IV, who were probably those at highest risk of
adverse outcome. Moreover, the patients who had recurrent episodes of
heart failure, worsening of symptoms, or cardiac death were balanced in
the Abl+Pm and drug groups, thus suggesting that the natural course of
the underlying disease, and not an adverse effect of ablation, was the
cause of the unfavorable outcome.
Finally, the results of the study did not evidence an increased risk of
death, especially sudden death, either early or late after ablation.
Early studies described sudden death in patients after DC ablation of
the AV junction.32 33 Life-threatening
ventricular arrhythmias and procedure-related death
have been observed in the immediate time period after radiofrequency
ablation.33 34 35 36 Concern has also been expressed
over the high mortality rate late after ablation, along with the
uncertainty whether this should be attributed to the natural course of
the underlying disease or to an adverse effect of the ablation and
pacemaker treatment.13 34 37 However, several
authors33 36 37 38 39 have identified DC ablation,
postablation bradycardia, failure of temporary pacing, very severe
heart failure, and hypokalemia as factors able to predict these
complications. Our results suggest that when the above-mentioned
factors are under control, life-threatening ventricular
tachyarrhythmias are unlikely to occur, that long-term
survival is similar to that observed in patients treated with
conventional therapy, and that the sudden death rate is slightly lower
in ablated patients. However, this conclusion needs further evidence
because our study did not have the power to show any slight differences
in mortality rates. To summarize, the different results of this study
compared with the previous uncontrolled studies give further
demonstration of the need to perform clinical trials including a
control group before considering a new treatment as established.
Conclusions
Received January 12, 1998;
revision received April 13, 1998;
accepted April 27, 1998.
© 1998 American Heart Association, Inc.
Clinical Investigation and Reports
Assessment of Atrioventricular Junction Ablation and VVIR Pacemaker Versus Pharmacological Treatment in Patients With Heart Failure and Chronic Atrial Fibrillation
A Randomized, Controlled Study
Abstract
Top
Abstract
Introduction
Methods
Results
Discussion
References
Background—Uncontrolled studies have
suggested that atrioventricular junction ablation and
pacemaker implantation have beneficial effects on quality of life in
patients with chronic atrial fibrillation (AF).
Key Words: catheter ablation • atrioventricular node • fibrillation • pacemakers
Introduction
Top
Abstract
Introduction
Methods
Results
Discussion
References
Although a few uncontrolled
studies1 2 3 4 have suggested the beneficial effect
of atrioventricular (AV) junction ablation during
long-term follow-up in patients with chronic AF, these did not include
a control group of patients with similar arrhythmias treated
without catheter ablation. A single controlled trial showed that
ablation was superior to medical therapy in improving specific symptoms
15 days after ablation.5 Rigorous quantification
of the impact of ablation therapy on specific symptoms and on the total
well-being of the person, including physical and psychological aspects,
has been performed only recently by Bubien et al6
in a wide variety of tachyarrhythmias. After ablation,
the patients with AF exhibited persistently lower quality-of-life
scores than those with the other types of arrhythmia. However,
baseline values were also significantly worse in AF patients; moreover,
chronic and paroxysmal AF were considered together. The main aim of
this study was to test the hypothesis that AV junction ablation and
VVIR pacemaker (Abl+Pm) treatment is superior to pharmacological
therapy in improving quality of life and controlling specific symptoms
during a long-term follow-up period in patients affected by manifest
heart failure and chronic AF. Secondary aims were to evaluate the
effect of ablation and pacemaker implantation on cardiac
performance and to assess the clinical complications of such
treatment.
Methods
Top
Abstract
Introduction
Methods
Results
Discussion
References
Protocol
This prospective, randomized, multicenter trial was designed to
compare the clinical efficacy of Abl+Pm treatment and conventional drug
therapy. Each patient was followed up for 12 months. Comparison was
performed at the end of this study period. The study protocol had been
approved by the Ethics Committee of the Hospital of Reggio Emilia and
by the institutional review committees of the hospitals participating
in the study. The enrolled subjects gave informed consent.
Randomization was effected centrally, blocking on study centers
to minimize possible biases caused by differences in patient
characteristics between centers. The allocation of sequences was
computer-generated and the intervention assignments were hidden from
participants in the trial until the time of allocation.
Consecutive patients affected by chronic AF (lasting >6 months)
who met all the following criteria were considered eligible for
inclusion: (1) clinically manifest heart failure responsible for
episodes of congestive heart failure or pulmonary edema or
persistent severe symptoms including palpitations, dyspnea, easy
fatigue, and chest discomfort that limited daily life and were
intolerable for the patient; (2) evidence of structural heart disease;
and (3) heart rate >90 bpm on 3 standard ECGs recorded at rest
during stable clinical conditions on different days.
The following were criteria for exclusion from the study:
end-stage heart failure; patients in class IV of the functional
classification of the New York Heart Association; acute
cardiovascular diseases during the previous 6 months,
for example, myocardial infarction, unstable angina, or stroke;
associated severe general medical illnesses; significant renal or
hepatic disease; history of sustained ventricular
tachyarrhythmias; follow-up not possible.
The primary end point was the evaluation of quality of life and
specific symptoms during the 12th month after randomization.
These were made at the time of enrollment and at the end of the
12-month study period.
A comprehensive evaluation of the patient's quality of life was
made with the Minnesota LHFQ.7 This 21-item,
self-administered questionnaire comprehensively covers physical,
socioeconomic, and psychological impairments occurring during the
previous month that patients often relate to their heart disease. A
score based on how each person ranks each item on a common scale is
used to quantify the extent of impairment and how it is affected by
therapeutic intervention. The maximum possible score is 105. In
patients with heart failure refractory to conventional therapy, the
median score proved to be 52; this decreased to 10 in
asymptomatic patients with heart
disease.7 In patients with severely
symptomatic paroxysmal AF uncontrolled by conventional
drugs, the mean score was 50 and decreased to 20 after AV junction
ablation and DDDR mode-switching pacemaker
treatment.8 The reliability and validity of this
questionnaire in detecting therapeutic benefits has been previously
demonstrated.8 9 10 11
The Specific Symptoms Scale was developed as a disease-specific
instrument to measure the patient's perception of the frequency and
severity of arrhythmia-related symptoms. This instrument has
been demonstrated to discern changes in the symptoms of patients with
atrial fibrillation both in sequential and in case-control
studies.5 It consists of a self-administered
semiquantitative questionnaire. Each patient is asked to quantify by
means of a score scale (0=absence, 10=maximum score) each of the
following symptoms occurring during the previous month: palpitations,
effort dyspnea (shortness of breath during physical activity), rest
dyspnea (shortness of breath at rest), exercise intolerance (fatigue
during mild physical activity), easy fatigue at rest, and chest
discomfort.
Functional capacity was also assessed objectively by the
investigators on enrollment and at the end of the study period, using
the 4-class functional classification of the NYHA.
The Specific Activity Scale assigns 1 to 4 functional classes on
the basis of the single most difficult activity the patient can perform
from a list of specific activities. It has been shown in particular to
be better than the NYHA classification for the evaluation of true class
II patients and less likely to underestimate treadmill
performance.12
The ablation end point was the production of complete,
persistent AV block. The ablation procedure was followed, after 1 hour,
by pacemaker implantation during the same session. All patients
received a single-chamber rate-responsive pacemaker. Unless otherwise
indicated, devices were programmed to the VVIR mode, a lower rate of 80
bpm, an upper rate limit of 120 bpm. The other programmable
parameters were set as appropriate for each individual
patient.
Patients from both groups underwent the commonly accepted
conventional treatments for heart failure, including digitalis,
diuretics, angiotensin-converting enzyme
inhibitors and nitrates. The patients assigned to the drug
arm were also treated with calcium-antagonists, sotalol,
and amiodarone when necessary to control rapid
ventricular heart rates. During the 12-month study period,
changes in drug therapy were permitted to minimize the patient's
discomfort and to further improve the treatment. ß-Blockers,
amiodarone, and calcium-antagonists were also used
in the Abl+Pm group when clinically indicated for other reasons.
Antithrombotic therapy was used in accordance with the published
guidelines.13 Anticoagulants were prescribed
whenever possible at a therapeutic value of INR of 2.5 (tolerance
limits 2 to 3). Antiplatelet therapy or no therapy was prescribed
when anticoagulants were contraindicated. In patients older than 75
years, the decision to adopt anticoagulant therapy was taken on the
basis of careful risk/benefit evaluation.
This study was performed on 
30 patients per group. On the
basis of a previous study,5 we assumed that the
Abl+Pm group had a 60% reduction in palpitations and a 50% reduction
in effort dyspnea scores compared with the drug group. This sample size
provided 80% power to show difference between groups with a
probability of 95%.
Results
Top
Abstract
Introduction
Methods
Results
Discussion
References
Participant Flow and Follow-up
Progress through the various stages of the trial, including flow
of participants, withdrawals, and timing of primary and secondary
outcome measures, are shown in the Figure
. Sixty-six
patients were enrolled. Screening logs were not maintained throughout
the trial, but we used data from intermittent surveys to calculate that
250 patients affected by heart failure and high rate chronic AF were
initially screened. The most frequent reason for noneligibilty was a
decrease of heart rate from an initial value >90 bpm to a value
<90 bpm during the run-in phase. Baseline characteristics of the study
population are shown in Table 1.
View larger version (33K):
[in a new window]
Figure 1. Progress through various stages of the trial, including flow
of participants, withdrawals, and timing of primary and secondary
outcome measurements.
View this table:
[in a new window]
Table 1. Baseline Characteristics of Study
Population
Primary End Point
At the end of the 12-month study period, the Abl+Pm group patients
showed significantly lower scores in palpitations (-78%) and effort
dyspnea (-22%) in comparison with those of the drug group (Table 2). When adjusted for baseline values,
exercise intolerance, easy fatigue, and chest discomfort also showed
significantly lower scores in the Abl+Pm group. Lower scores, although
not significant, were also observed for LHFQ, NYHA functional
classification, and activity scale.
View this table:
[in a new window]
Table 2. Results of Quality-of-Life Measurements in 28
Patients of Abl+Pm Arm and 26 Patients of Drug Arm Who Completed
12-Month Study Period
The intrapatient comparisons between enrollment and month 12 are
shown in Table 2
. There was some improvement in both groups. In the
Abl+Pm group all variables improved significantly, except for easy
fatigue, from 14% to 82%. In the drug group the scores for LHFQ,
palpitation, rest dyspnea, and easy fatigue improved significantly.
NYHA class improved in 46% and 37% of the patients and worsened in
7% and 19%, respectively. Activity scale improved in 36% and 33% of
the patients and worsened in 7% and 12%, respectively (not
significant). . Complications related to ablation
occurred in 2 patients: In a patient with severe heart failure an
episode of ventricular fibrillation occurred 12 hours after
ablation; this was possibly related to inappropriate programming of his
permanent pacemaker (inadvertent night-rate drop to a rate
of 50 bpm); in the other patient, pulmonary embolism occurred 2
days after ablation, with subsequent full recovery. No complications
related to pacemakers were observed during the follow-up.
View this table:
[in a new window]
Table 3. Clinical Events in Randomized Population During
12-Month Study Period ). In the subgroups of patients
with ejection fraction 
40% on enrollment, the ejection fraction
value was seen, at the month-12 visit, to have increased by 4±10
points in the Abl+Pm group and by 4±16 in the drug group (not
statistically different).
View this table:
[in a new window]
Table 4. Echocardiographic, Exercise Stress Test, and Holter
Recording Results in 28 Patients of Abl+Pm Arm and 26 Patients of Drug
Arm Who Completed 12-Month Study Period ). Antiarrhythmic and
cardiovascular drugs administered throughout the study
are shown in Table 5. Therapy remained
stable during the study period, with a predominance of
calcium-antagonist therapy in the drug group and of nitrate
therapy in the Abl+Pm group.
View this table:
[in a new window]
Table 5. Antiarrhythmic and Cardiovascular Drugs Administered
Throughout Study in 28 Patients of Abl+Pm Arm and 26 Patients of Drug
Arm Who Completed 12-Month Study
Period
In the drug group, a total of 10 patients received ablation and
pacemaker treatment because of worsening of their symptoms, 4 before
the completion of the study and 6 immediately after the month-12 visit,
and continued to be followed-up. In 7 of these, outcome measurements
were obtained at the time of ablation and 1 year later (Table 6). Ablation and pacemaker treatment
caused not only an improvement compared with the time of ablation but
also a significant improvement over the initial evaluation on
enrollment, being of similar magnitude to that observed in the Abl+Pm
group.
View this table:
[in a new window]
Table 6. Intrapatient Comparison of Quality-of-Life
Measurements in 7 Patients of Drug Arm Who Underwent Secondary Ablation
and Pacemaker Implantation
Discussion
Top
Abstract
Introduction
Methods
Results
Discussion
References
To date, ablation and pacemaker treatment of chronic AF have not
been evaluated against a control group of medically treated patients
during a long follow-up period. We enrolled a heterogeneous
population affected by heart failure and AF with a relatively high
ventricular rate that caused severe symptoms of heart
failure. The characteristics of the population were similar to those of
other studies. For example, the mean LHFQ score before ablation was as
high as that of 38 to 48 registered by patients with heart failure
refractory to conventional therapy who were undergoing studies on the
effects of new pharmacological agents.9 10 11 The
1-year mortality rate of our population was 11%, which is very similar
to that of the large series of patients affected by AF and
mild-to-moderate heart failure enrolled in the V-HeFT II
study.14
All previous studies showed that after ablation and pacemaker
implantation, patients did better and had improved indexes of quality
of life of a similar magnitude to that observed by us in the Abl+Pm
group. For example, Natale et al4 ranked
palpitations, effort dyspnea, rest dyspnea, exercise intolerance, and
easy fatigue, and, after 12 months, found an improvement ranging from
46% to 88%. In our previous study,5 the items
of the Specific Symptom Scale had improved by 48% to 96% (3 months
from ablation). Geelen et al16 evaluated LHFQ at
the baseline and after 6 months and found a 39% decrease (from 36 to
22) in this index. Ellenbogen et al17 found an
improvement of 37% in their Physical Function score, of 135% in
Physical Limits, and of 46% in Functional Quality of Life, 12 months
after ablation. Fitzpatrick et al2 observed a
94% increase in their Quality of Life index; moreover, the pooled
score of All Activities increased by 26%. A significant decrease in
NYHA class has also been observed.4 5 17 Because
of its controlled design, our study demonstrates that not all the
benefits were due to ablation and pacemaker treatment per se, as some
improvement occurred also in the conventional treatment group. Several
factors other than ablation and pacemaker therapy may have contributed
to determining the final results on outcome, including more thorough
examinations during the study than before, higher motivation of the
patients to treat their disease, and an unrecognized clinical
instability at the time of enrollment. However, it is well known that
many patients, even those affected by end-stage heart failure, may
experience an unexpected reversal of their heart
failure.18
In patients with heart failure and chronic AF, the control of
rapid and irregular heart rate achieved by ablation and pacemaker
treatment can be proposed, in addition to conventional pharmacological
therapy, as an efficacious means of improving quality of life without
exposing patients to serious adverse effects, complications, or death.
However, this study was unable to show a benefit of the treatment on
cardiac performance or on the progression of the disease.
References
Top
Abstract
Introduction
Methods
Results
Discussion
References
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V. Fuster, L. E. Ryden, D. S. Cannom, H. J. Crijns, A. B. Curtis, K. A. Ellenbogen, J. L. Halperin, J.-Y. Le Heuzey, G. N. Kay, J. E. Lowe, et al. ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation) Developed in Collaboration With the European Heart Rhythm Association and the Heart Rhythm Society J. Am. Coll. Cardiol., August 15, 2006; 48(4): e149 - e246. [Full Text] [PDF]
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J. S. Steinberg Desperately Seeking a Randomized Clinical Trial of Resynchronization Therapy for Patients With Heart Failure and Atrial Fibrillation J. Am. Coll. Cardiol., August 15, 2006; 48(4): 744 - 746. [Full Text] [PDF]
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M. Gasparini, A. Auricchio, F. Regoli, C. Fantoni, M. Kawabata, P. Galimberti, D. Pini, C. Ceriotti, E. Gronda, C. Klersy, et al. Four-Year Efficacy of Cardiac Resynchronization Therapy on Exercise Tolerance and Disease Progression: The Importance of Performing Atrioventricular Junction Ablation in Patients With Atrial Fibrillation J. Am. Coll. Cardiol., August 15, 2006; 48(4): 734 - 743. [Abstract] [Full Text] [PDF]
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 V. Fuster, L. E. Ryden, D. S. Cannom, H. J. Crijns, A. B. Curtis, K. A. Ellenbogen, J. L. Halperin, J.-Y. Le Heuzey, G. N. Kay, J. E. Lowe, et al. ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): Developed in Collaboration With the European Heart Rhythm Association and the Heart Rhythm Society Circulation, August 15, 2006; 114(7): e257 - e354. [Full Text] [PDF]
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V. Fuster, L. E. Ryden, D. S. Cannom, H. J. Crijns, A. B. Curtis, K. A. Ellenbogen, J. L. Halperin, J.-Y. Le Heuzey, G. N. Kay, J. E. Lowe, et al. ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation--Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): Developed in Collaboration With the European Heart Rhythm Association and the Heart Rhythm Society Circulation, August 15, 2006; 114(7): 700 - 752. [Full Text] [PDF]
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Authors/Task Force Members, V. Fuster, L. E. Ryden, D. S. Cannom, H. J. Crijns, A. B. Curtis, K. A. Ellenbogen, J. L. Halperin, J.-Y. Le Heuzey, G. N. Kay, et al. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation executive summary: A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients with Atrial Fibrillation) Developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society Eur. Heart J., August 2, 2006; 27(16): 1979 - 2030. [Full Text] [PDF]
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 T. Szili-Torok, M. Bountioukos, A. J.Q.M. Muskens, D. A.M.J. Theuns, D. Poldermans, J. R.T.C. Roelandt, and L. J. Jordaens The presence of contractile reserve has no predictive value for the evolution of left ventricular function following atrio-ventricular node ablation in patients with permanent atrial fibrillation Eur J Echocardiogr, October 1, 2005; 6(5): 344 - 350. [Abstract] [Full Text] [PDF]
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M. Brignole, M. Gammage, E. Puggioni, P. Alboni, A. Raviele, R. Sutton, P. Vardas, M.G. Bongiorni, L. Bergfeldt, C. Menozzi, et al. Comparative assessment of right, left, and biventricular pacing in patients with permanent atrial fibrillation Eur. Heart J., April 1, 2005; 26(7): 712 - 722. [Abstract] [Full Text] [PDF]
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 L.-F. Hsu, P. Jais, P. Sanders, S. Garrigue, M. Hocini, F. Sacher, Y. Takahashi, M. Rotter, J.-L. Pasquie, C. Scavee, et al. Catheter Ablation for Atrial Fibrillation in Congestive Heart Failure N. Engl. J. Med., December 2, 2004; 351(23): 2373 - 2383. [Abstract] [Full Text] [PDF]
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P. R. Kowey You only get so many heartbeats... J. Am. Coll. Cardiol., April 7, 2004; 43(7): 1209 - 1210. [Full Text] [PDF]
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