Abstract
Background: The Ablate and Pace Trial (APT) prospectively assessed the effects of catheter ablation of the AV conduction system and permanent pacemaker implantation on health-related quality of life, survival, exercise capacity, and ventricular function in 156 patients with symptomatic atrial fibrillation. Methods: All patients referred for catheter ablation and permanent pacemaker implantation because of medically-refractory atrial fibrillation at 16 centers were screened for enrollment in a prospective registry. Baseline assessment prior to ablation included measurement of quality of life, including the Health Status Questionnaire, the Quality of Life Index and the Symptom Checklist: Frequency and Severity. Exercise capacity was assessed with metabolic treadmill exercise testing and ventricular function was quantitated with echocardiography. The quality of life instruments, exercise capacity, and echocardiography were repeated at 3 and 12 months after catheter ablation. Results: The APT population included 90 men and 66 women (66.1 ± 11.5 years of age) with either chronic (n = 70), recurrent (n = 31), or paroxysmal atrial fibrillation (n = 55). Structural heart disease was present in 78.2% of patients. Successful ablation of AV conduction was achieved in 155 of 156 patients (99.4%). Survival at 1 year was 85.3%, with 5 of 23 deaths being sudden cardiac deaths. Survival over the first year of follow-up was significantly lower for patients with a baseline left ventricular ejection fraction (LVEF) <0.45 (0.73) than for patients with a LVEF ≤0.45 (0.88, p = 0.03). The NYHA functional class improved from 2.1 at baseline to 1.8 at 3 months and 1.9 at 12 months of followup (p = 0.0001). Significant improvement in quality of life scores were noted for all 8 subscales of the Health Status Questionnaire, for the overall rating of the Quality of Life Index, the Health and Function subscales; Arrhythmia-related symptoms were markedly reduced as measured by the Symptom Checklist: Frequency and Severity scale. The mean LVEF improved from 0.50 ± 0.20 at baseline to 0.54 ± 0.20 at 3 months (p = 0.03). The LVEF 12 months after ablation was 0.52 ± 0.20, not statistically different from baseline. Individuals with reduced systolic function at baseline had the greatest improvement, from LVEF 0.31 ± 0.20 at baseline to 0.41 ± 0.20 at 3 months and 0.41 ± 0.30 at 12 months (p = 0.0001). There were no significant changes in treadmill exercise duration (10.0 ± 4.3 min at baseline and 11.6 ± 3.6 min at 12 months) or VO2max (1467 ± 681 ml O2 min baseline and 1629 ± 739 ml O2 min at 12 months). Conclusions: Catheter ablation of the AV conduction system and permanent pacemaker implantation were associated with improved quality of life and left ventricular function in this population of highly symptomatic patients with atrial fibrillation refractory to medical therapy.
Similar content being viewed by others
References
Gallagher JJ, Svenson RH, Kasell JH, et al. Catheter technique for closed-chest ablation of the atrioventricular conduction system. N Engl J Med 1982;306:194-200.
Scheinman MM, Morady F, Hess DS, et al. Closed-chest catheter desiccation of the atrioventricular junction using radiofrequency energy-a new method of catheter ablation. J Am Coll Cardiol1987;9:349-358.
Kay GN, Bubien RS, Epstein AE, et al. Effect of catheter ablation of the atrioventricular junction on quality of life and exercise tolerance in paroxysmal atrial fibrillation. Am J Cardiol1988;62:741-744.
Huang SK, Bharati S, Graham AR, et al. Closed-chest catheter desiccation of the atrioventricular junction using radiofrequency energy-a new method of catheter ablation. J Am Coll Cardiol 1987;9:349-358.
Langberg JJ, Chin MC, Rosenqvist M, et al. Catheter ablation of the atrioventricular junction with radiofrequency energy. Circulation 1989;80:1527-1535.
Langberg JJ, Chin MC, Schamp DJ, et al. Ablation of the atrioventricular junction with radiofrequency using a new electrode catheter. Am J Cardiol 1991;67:142-147.
Jackman WM, Wang X, Friday KJ, et al. Catheter ablation of atrioventricular junction using radiofrequency current in 17 patients: Comparison of standard and large-tip catheter electrodes. Circulation 1991;83:1562-1576.
Yeung-Lai-Wah JA, Alison JF, Lonergan L, et al. High success rate of atrioventricular node ablation with radiofrequency energy. J Am Coll Cardiol1991;18:1753-1758.
Morady F, Calkins H, Langberg JJ, et al. A prospective randomized comparison of direct current and radiofrequency ablation of the atrioventricular junction. J Am Coll Cardiol1993;21:102-109.
Olgin JE, Scheinman MM. Comparison of high energy direct current and radiofrequency catheter ablation of the atrioventricular junction. J Am Coll Cardiol1993;21:557-564.
Twildale N, Sutton K, Bartlett L, et al. Effects on cardiac performance of atrioventricular node catheter ablation using radiofrequency current for drug-refractory atrial arrhythmias. JACC 1993;16:1275-1283.
Heinz G, Siostrzonek P, Kreiner G, et al. Improvement in left ventricular systolic function after successful radiofrequency His bundle ablation for drug refractory, chronic atrial fibrillation and recurrent atrial flutter. Am J Cardiol 1992;69: 489-492.
Bernstein AD, Parsonnet V. Survey of cardiac pacing and defibrillation in the United States in 1993. Am J Cardiol1996;78:187-196.
Wilkoff BL, Corey J, Blackburn G. A mathematical model of the cardiac chronotropic response to exercise. J Electrophysiol 1989;3:176-180.
Blackburn G, Harvey S, Wilkoff BL. A chronotropic assessment exercise protocol to assess the need and efficacy of rate responsive pacing. Med Sci Sports Exerc. 1988;20:S21(Abstract).
Ware JE and Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care 1992;30(6):473-83.
Ware JE. SF-36 health survey: Manual and interpretation guide. Boston: The Health Institute, New England Medical Center. 1993.
McHorney CA, Ware JE, Raczek AE. The MOS 36-Item Short-Form Health Survey (SF-36), II: psychometric and clinical tests of validity im measuring physical and mental health constructs. Med Care. 1993;31:247-263.
Stewart AL, Sherbourne CD, Hays RD, Welks KB, Rogers WH, Berry SH, Ware JE. Summary and discussion of MOS measures. In: Stewart AL, Ware JE, eds. Measuring Functioning and Well-being: The Medical Outcomes Study Approach. Durham, NC: Duke University Press, 1992:345-372.
Wicklund I, Gorkin K, Pawitan Y, Schron E, Schoenberger J, Jared LL, Shumaker S, for the CAST Investigators. Methods for assessing quality of life in the Cardiac Arrhythmia Suppression Trial (CAST). Quality of Life Research 1992;1:187-201.
Bubien RS, Knotts-Dolson SM, Plumb VJ, Kay GN. Effect of radiofrequency catheter ablation on health-related quality of life and activities of daily living in patients with recurrent arrhythmias. Circulation 1996;94:1585-1591.
Henry WL, DeMaria A, Gramiak R, et al. Report of the American Society of Echocardiography Committee on Nomeclature and Standards in Two-Dimensional Echocardiography. Circulation 1980;62:212.
Tajik AJ, Seward JB, Hagler DJ, Mair DD, Lei JT. Two-dimensional real-time ultrasonic imaging of the hear and great vessels: Technique, image orientation, structure indentification, and validation. Mayo Clinic Proceedings 1978;53:271-303.
Nishimura RA, Miller RF, Callagan. Doppler echocardiography: Theory, instrumentation, technique, and application. Mayo Clinic Proceedings 1985;60:321-343.
Quinones MA, Waggoner AD, Reduto LA. A new, simplified and accurate method for determining ejection fraction with two-dimensional echocardiography. Circulation 1981;64 744-753.
Beaver WL, Wasserman K, Whipp BJ. A new method for detecting the anaerobic threshold by gas exchange.J Appl Physiol1986;60:2020-2027.
Lawless, JE.Statistical Models and Methods for Lifetime Data. New York: Wiley and Sons, 1982.
Epstein AE, Carlson MD, Fogoros RN, Higgins SL, Venditti FJ. Classification of death in antiarrhythmia trials. J Am Coll Cardiol 1996;27:433-442.
Brugada P, de Swart H, Smeets JL, et al. Transcoronary chemical ablation of atrioventricular junction. Circulation 1990;81:757-761.
Evans GT, Scheinman MM, and the Executive Committee of the Registry. The percutaneous cardiac mapping and ablation registry: Summary of results. PACE1987;10:1395-1399.
Levy S, Bru P, Aliot E, et al. Long-term follow-up of atrioventricular junctional transcatheter electrical ablation. PACE 1988;11:1149-1153.
Evans GT, Scheinman MM, Bardy G, et al. Predictors of in-hospital mortality after DC catheter ablation of atrioventricular junction: Results of a prospective, international, multicenter study. Circulation 1991;84:1924-1937.
Auricchio A, Klein H, Trappe HJ, et al. Effect on ventricular performance of direct current electrical shock for catheter ablation of the atrioventricular junction. PACE 1992;15:344-356.
Wenger N, Matson M, Furberg C, Elinson J, eds. Assessment of Quality of Life in Clinical Trials of Cardiovascular Therapies. New York: Le Jacq Publishing, Inc., 1984: preface.
Kay GN, Epstein AE, Daily SM, Plumb V.I. Role of radiofrequency ablation in the management of supraventricular arrhythmias: Experience in 760 consecutive patients.J Cardiovasc Electrophysiol1993;4:371-389.
Calkins H, Langberg J, Sousa J, El-Atassi R, Leon A, Kou W, Kalbfleisch S, Morady F. Radiofrequency catheter ablation of accessory atrioventricular connections in 250 patients. Circulation1992;85:1337-1346.
Calkins H, Sousa J, El-Atassi R, Rosenheck S, De Buitleir M, Kou WH, Kadish AH, Langberg JJ, Morady F. Diagnosis and cure of the Wolff-Parkinson-White syndrome or paroxysmal supraventricular tachycardias during a single electrophysiologic test. N Engl J Med1991;324:1612-1618.
Jackman WM, Xunzhang W, Friday KJ, Roman CA, Moulton KP, Beckman KJ, McClelland JH, Twidale N, Hazlitt A, Prior MI, Margolis PD, Calame JD, Overholt ED, Lazzara R. Catheter ablation of accessory atrioventricular pathways (Wolff-Parkinson-White syndrome) by radiofrequency current. N Engl J Med 1991;324:1605-1611.
Packer DL, Bardy GH, Worley SJ, et al. Tachydia-induced cardiomyopathy: A reversible form of left ventricular dysfunction. Am J Cardiol 1986;57:563-570.
McLaren CJ, Gersh BJ, Sugrue DD, et al. Tachycardia induced myocardial dysfunction: A reversible phenomenon? Br Heart H 1985;53:323-327.
Tomita M, Spinale FG, Crawford FA, et al. Changes in left ventricular volume, mass and function during the development and regression of supraventricular tachycardia-induced cardiomyopathy. Disparity between recovery of systolic versus diastolic function. Circulation 1991;83:635-644.
Grogan M, Smith HC, Gersch BJ. Left ventricular dysfunction due to atrial fibrillation in patients initially believed to have idiopathic dilated cardiomyopathy. Am J Cardiol1992;69:1570-1573.
Cruz FE, Cheriex EC, Smeets JL, et al. Reversibility of tachycardia induced cardiomyopathy after cure of incessant supraventricular tachycardia. J Am Coll Cardiol 1990;16: 739-744.
Rights and permissions
About this article
Cite this article
Kay, G.N., Ellenbogen, K.A., Giudici, M. et al. The Ablate and Pace Trial: A Prospective Study of Catheter Ablation of the AV Conduction System and Permanent Pacemaker Implantation for Treatment of Atrial Fibrillation . J Interv Card Electrophysiol 2, 121–135 (1998). https://doi.org/10.1023/A:1009795330454
Issue Date:
DOI: https://doi.org/10.1023/A:1009795330454