Rheumatic heart disease with persistent AF: role of atrial lead in pace and ablate strategy

Introduction

Outcome of catheter ablation in AF is questionable in patients with persistent/permanentAF(pAF) of >3 years in structural heart disease, dilated left atrium (LA)and underlying left ventricular dysfunction.Hence, these patientscan be considered for pace and ablate strategy(PAS) with conduction system pacing or biventricular pacing (BiV).Once we considerPAS, rhythm control is ruled out. But, with the utilization of PASsupplemented with right atrial lead(RAL) in rheumatic heart diseasewith pAF (RHD-pAF), we could achieve normal sinus rhythm(NSR) in 45% of patientsin the past. Thus, we named this strategy a hybrid approach. Due to control of ventricular rate and treatment of irregulopathy, there was reverse remodeling, which facilitated achievement of NSR in few such patients. This emphasizes the importance of the placement of RAL in patients undergoing PAS, which can be utilized in the future to maintainatrio-ventricularsynchrony.

Purpose

The purpose of the study is to evaluate the importance of placement of RAL in patients undergoing PAS in whom step wise approach was used for the management of RHD-pAF.

Methods

From our RHD-AF registry, we performed PAS in 42/120 patients. Out of 42, RAL was implanted in 39 patients which formed our study cohort. Clinical parameters of improvement such as echocardiography, NYHA class, diuretic burden, and heart failure (HF) hospitalization following device implantation were measured during the 36.21±17.52 months of follow up. Statistical analysis was done using an independent Sample t test(continuous variable) and chi-square test(categorical variable).

Results

Mean age of the study population was 61.75 ± 8.1years and 27/37(73%) were female(Table 1). Mean left ventricular ejection fraction (LVEF) was 55.84±9.6% and 27/37(73%) patients presented in NYHA class III/IV. 31/37 (83.78%) had prior valvular intervention,12/37(32.43%) patients had history of HF hospitalization, and 9/37(24.32%) patients had history of stroke.

Post procedure over mean duration 36.21±17.52 months of follow-up: 18/37(48.64%) patients could be reverted to and maintain NSR during the period of follow-up. Although 8/18(44.44%) had breakthrough episodes of self-terminating AF. All patients showed improvement in NYHA class, with improvement in LA size(4.53±0.61cm) and left ventricular end systolic diameter LVESD(3.16±0.66cm). The use of amiodarone decreased to 2/37(5.4%) from previous 7/37(18.91%). The use of diuretics decreased from 73% to 64% and no HF hospitalizations over 36.21±17.52months of follow-up. Patients who could not achieve NSR had higher BMI, more co-morbidities(table 1). They had larger LA size, LVESD, lower LVEF requiring BiV with a defibrillator

Conclusion

Thus, RAL implantation can be considered in patients undergoing pace and ablate strategy in RHD-pAF with dilated LA, as with the control of ventricular rate and irregulopathy these patients can achieve NSR over time.