47 Pace and ablate strategy in patients with near normal left-ventricular systolic function: PPM or CRT?. (May 2019)

• Record Type: Journal Article
• Authors: Dennis, Adam; Moore, Philip; Cambridge, Alexander; Monkhouse, Christopher; Chow, Anthony; Behar, Jonathan M
• Is Part Of: Heart. Volume 105(2019)Supplement 6
• Page Start: A40
• Page End: A41
• Publication Date: 2019-05
• Subjects: Pacing and Cardiac Resynchronisation Therapy -- AV Node ablation -- Atrial Fibrillation; Heart -- Diseases -- Treatment -- Periodicals; Cardiology -- Periodicals; 616.12
• DOI: 10.1136/heartjnl-2019-BCS.45
• Languages: English
• ISSNs: 1355-6037

Abstract

Abstract : Introduction: The European Society of Cardiology 2016 atrial fibrillation (AF) guidance suggests atrioventricular node (AVN) ablation and pacemaker implantation in patients with AF unresponsive to rate and rhythm control therapies.1 For patients with conventional cardiac resynchronisation therapy (CRT) indications and AF, the recommendations are clear. However, in patients with normal left ventricular (LV) function and a pace and ablate strategy, there is limited evidence to support biventricular pacing (CRT) in favour of conventional right-ventricular permanent pacemakers (PPM). We audited our practice of AVN ablation to evaluate the current practice in our institution, and to observe for differences between pacing groups. Methods: Our devices database was searched for patients who underwent AV node ablation between June 2016 to September 2018. Descriptive and statistical analysis were performed, using t-test and Chi-squared methods. Results: 142 patients underwent AV node ablation, and 56 patients were identified with preserved LV function (LVEF > 50%) with a pace and ablate management strategy. Of these patients, 35 had a PPM, and 21 a CRT implanted prior to ablation. Comparing these groups, patients undergoing pacemaker implantation were significantly older (PPM 76± 14 vs CRT 67± 11, p= 0.014). There was also a significant difference in male gender, (PPM 8 (22.9%) vs CRT 13 (61.9%), p= 0.0035). Mean LVEF was similar between PPM and CRT groups (56±4% vs. 53±3%). There was a trend in higher background ischaemic heart disease in the CRT group (CRT 3 (14.2%) vs. PPM 1 (2.9%), p=0.108). At initial device implantation, two patients intended for CRT had a failed attempt at LV lead placement (5.7%), therefore a PPM was implanted. Device procedure time appears longer in the CRT group (CRT 132.1 mins ± 40.9, vs. PPM 85.8 mins ± 34.8). Total mean follow-up period was 345 days (± 197). Two patients (5.7%) in the PPM group required lead revisions, compared to none in the CRT group. A total of two patients required repeat procedures for failed ablations, with no other procedural complications. There was a trend in higher all cause mortality in the PPM group compared with the CRT group (4 (11.4%) vs. 1 (4.8%), p= 0.397). Discussion and conclusion: The BLOCK HF trial demonstrated that biventricular pacing was superior to right-ventricular pacing in patients with an LVEF <50%.2 The role of prophylactic CRT implantation in patients with preserved LV was addressed in the BIOPACE trial, however these results were not formally published and controversy still exists about the type of device to implant in patients with near normal LV function. 3 Our study describes the variability in our clinical practice given the split in PPM vs CRT in patients with near normal LV function. The increased age and mortality trend in the PPM group may reflect an increased frailty or co-morbidity compared with the CRT group. However, long term clinical outcomes are required in order to provide clarity on this important clinical decision. Conflict of Interest: None