Ablation vs Medical Therapy in the Setting of Symptomatic Atrial Fibrillation and Left Ventricular Dysfunction

Abstract

Small, single-center studies suggest that catheter ablation of atrial fibrillation (AF) can improve ventricular function and reduce symptoms in patients with left ventricular (LV) dysfunction. However, ablation has not been compared with a pharmacologic strategy for AF. The authors evaluated patients with AF and symptomatic LV dysfunction (ejection fraction < or =45%) referred for pulmonary vein isolation (PVI). They compared these patients with a matched cohort treated medically for AF and LV dysfunction via a retrospective case-control method. Fifteen patients (14 men, 56+/-11 years, 10 [67%] paroxysmal AF) with AF for 4+/-3 years underwent PVI. Baseline ejection fraction was 37%+/-6% and New York Heart Association (NYHA) class was 2.0+/-1.0. Fifteen controls (13 men, 63+/-14 years, 11 [73%] paroxysmal AF) with AF for 5+/-4 years were treated medically for AF. Baseline ejection fraction was 34%+/-11% and NYHA class was 2.0+/-0.7. The groups were similar in all respects. During a follow-up of 16+/-13 months after complete PVI, ejection fraction improved (P=.001) to 50%+/-13% and normalized in 8 patients (53%). NYHA class improved to 1.3+/-0.5 (P=.01). In the medically treated group, after follow-up of 16+/-12 months, no improvement in ejection fraction (36%+/-12%) or NYHA class (1.8+/-0.7) was seen. Compared with pharmacologic therapy, PVI significantly improved LV function and NYHA class in patients with AF and symptomatic LV dysfunction. These provocative findings provide potent rationale for a randomized clinical trial comparing ablation with pharmacologic therapy.