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Europace Advance Access originally published online on February 12, 2008
Europace 2008 10(4):412-418; doi:10.1093/europace/eun020
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Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2008. For permissions please email: journals.permissions@oxfordjournals.org

'ABLATE AND PACE': STILL A VALID TREATMENT FOR AF

Long-term outcome of the atrioventricular node ablation and pacemaker implantation for symptomatic refractory atrial fibrillation

Eng S. Tan1, Michiel Rienstra1, Ans C.P. Wiesfeld1, Bas A. Schoonderwoerd1, Hugo H.F. Hobbel1 and Isabelle C. Van Gelder1,2,*

1 Department of Cardiology, Thoraxcenter, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands; 2 The Interuniversity Cardiology Institute Netherlands, Utrecht, The Netherlands

Manuscript submitted 1 November 2007. Accepted after revision 12 January 2008.

* Corresponding author. Tel: +31 50 3612355; fax: +31 50 3614391. E-mail address: i.c.van.gelder{at}thorax.umcg.nl


   Abstract
Top
 Abstract
Introduction
 Methods and patients
 Results
 Discussion
 Conclusions
 References
 
Aims: To investigate long-term outcome and to determine predictors of development of heart failure (HF) in patients with atrioventricular (AV) node ablation and permanent right ventricular pacing because of symptomatic refractory atrial fibrillation (AF).

Background: Atrioventricular node ablation and subsequent permanent pacing is a well-established therapy for patients with AF. Long-term right ventricular pacing may induce HF.

Methods and results: In 121 (45 with previous HF) patients with drug refractory AF, AV node ablation and implantation of a pacemaker was performed. At baseline and after a mean follow-up of 4.3 ± 3.3 years, New York Heart Association (NYHA) functional class for HF and left ventricular (LV) and atrial diameters were assessed. During and at the end of follow-up, hospitalizations for HF, mortality, and quality of life were assessed using the SF-36 and an AVN-specific questionnaire. No significant changes in NYHA functional class (87 vs. 77% in NYHA I/II at baseline vs. end of follow-up) and LV end diastolic diameter (51 ± 7 vs. 52 ± 8 mm) were observed. Left ventricular end systolic diameter decreased (from 37 ± 9 to 34 ± 7 mm, P = 0.03) and fractional shortening improved (from 28 ± 10 to 34 ± 9, P = 0.02) in all patients and in patients with previous HF, but not in patients without previous HF. Hospitalizations for HF occurred in 24 patients (20%), predominantly those with previous HF. All-cause mortality occurred in 31 (26%) patients. At the end of follow-up, quality of life was comparable with the control group.

Conclusion: Long-term outcome of AV node ablation and permanent pacing is good. Atrioventricular node ablation remains a treatment option for AF.

Key Words: Atrial fibrillation, Atrioventricular node ablation, Right ventricular pacing


   Introduction
Top
 Abstract
 Introduction
Methods and patients
 Results
 Discussion
 Conclusions
 References
 
Randomized controlled trials have shown that rate-control therapy is not inferior to rhythm-control therapy.1Go,2Go Therefore, rate control is adopted more frequently as first-choice therapy. Rate control, however, is not always easy to achieve. In the AFFIRM study, frequent dose adjustments and medication changes were needed, and the strict rate-control target was only achieved in 70% of all patients.3Go Atrioventricular (AV) node ablation and permanent pacing is a well-established therapeutic strategy for atrial fibrillation (AF) and provides highly efficient rate control. It improves symptoms in selected patients.4Go–7Go Previously, this approach was more often performed, as atrial catheter ablation was not a therapeutic option at that time.8Go However, even in these days, AV node ablation remains an important treatment option in patients in whom rhythm control is ineffective or causing severe adverse effects.9Go,10Go However, this approach has several limitations, including lifelong right ventricle pacing. Recent studies in patients with an implantable cardioverter defibrillator and left ventricular (LV) dysfunction and studies in patients with initially normal LV function have shown that right ventricular pacing may be associated with an increased risk of impairment of cardiac function and heart failure (HF) and may induce LV dyssynchrony and more AF.11Go–16Go It is still unclear whether cardiac resynchronization therapy may be beneficial in these patients. A recent meta-analysis reported that cardiac resynchronization therapy in stead of right ventricular pacing may improve outcome, especially in patients with permanent AF and HF.17Go

The purpose of this study was to investigate long-term outcome and to determine predictors of development of HF in patients with AV node ablation and permanent right ventricular pacing because of symptomatic refractory AF.


   Methods and patients
Top
 Abstract
 Introduction
 Methods and patients
Results
 Discussion
 Conclusions
 References
 
Patient population
The present patient population consists of 121 consecutive patients with AF, including 45 (37%) patients with a previous hospitalization for HF. All patients underwent a pacemaker implantation and subsequently a successful radiofrequency catheter AV node ablation at the University Medical Center Groningen, Groningen, The Netherlands, between January 1997 and January 2007. Indications for AV node ablation were severely symptomatic paroxysmal or permanent AF despite the use of at least two antiarrhythmic drugs, or severe adverse events on rate- or rhythm-control drugs. Exclusion criteria were New York Heart Association (NYHA) functional class IV and age <18 years.

Procedure of pacemaker implantation and atrioventricular node ablation
All patients had a DDD-R or a VVI-R pacemaker implanted before treatment, for paroxysmal or permanent AF, respectively. The ventricular pacing lead was routinely placed in the right ventricular apex and the atrial lead in the right atrial appendage. Standard techniques were used for radiofrequency ablation of the AV node.18Go,19Go AV node ablation was performed principally (94%) with a quadripolar thermocouple ablation catheter (Biosense Webster Inc., Diamond Bar, CA, USA, curve D or F), accessed through the femoral vein. Ablation was performed using a conventional right-sided approach in every case with radiofrequency energy. Patients were subsequently followed-up in the outpatient clinic. Routinely, pacing was performed in the VVI-R or DDD-R mode with a lower rate of 90 bpm during the first months to prevent any clinical problem related to the sudden reduction of heart rate.20Go Thereafter, the lower rate was decreased to 60–80 bpm.

Data collection
Patient history and baseline characteristics were obtained using patient medical records and the centralized patient record system. All AV node ablation parameters were retrieved from computerized operation reports. In all patients, NYHA functional class was determined before ablation, as well as a transthoracic echocardiography and a 12-lead electrocardiogram were performed. Heart failure at baseline was determined as previous hospitalization for HF. Renal function was assessed by serum creatinine and calculation of the glomerular filtration rate using the simplified modification of diet renal disease equation [186 x serum creatinine–1.154 (mg/dL) x age–0.203 (years) x 0.742 if female].

Follow-up
All patients were seen every 6 months at the outpatient department. Severe cardiovascular complications during follow-up were determined, including hospitalizations for HF and all-cause mortality. Heart failure during follow-up was defined as hospitalization for HF. Both the time of death and the mode of death were determined using information from the treating physicians, or general practitioners. In case of incomplete data, a national registry was used. For that reason, we cannot provide complete data on the cause of cardiovascular mortality. Changes in NYHA functional class, changes in antiarrhythmic drug use, and changes in echocardiographic parameters between baseline and follow-up were assessed. Duration of follow-up was calculated from the time of AV node ablation to death or to the date when the last follow-up data were obtained.

Quality of life
At the end of follow-up, quality of life was assessed using the Medical Outcomes Study Short-Form Health Survey (SF-36) questionnaire.21Go The SF-36 questionnaire is a standardized, validated, generic health survey that has been frequently used in arrhythmia studies.21Go The SF-36 has been translated and validated in the Netherlands.22Go It contains items to assess physical health (e.g. general health perception, physical functioning, role limitations due to physical problems, and bodily pain) and mental health (social functioning, role limitations due to emotional problems, mental health, and vitality). The quality of life of AV node ablation patients was compared with a control population with a comparable age and gender distribution. In addition, we compiled a specific AV node ablation survey form with concise questions on the topic in order to assess additional information about the AV node ablation procedure, previously used for patients who underwent Maze surgery.23Go

Statistical analysis
Descriptive statistics are presented as the mean ± SD or median (range) for continuous variables and counts with percentages for categorical variables. In case of normally distributed variables, the Student t-test, otherwise the Mann–Whitney U-test, was used. Paired t-tests were used for the comparison of the study population at a different follow-up time. Kaplan–Meier estimates were performed to study the occurrence of hospitalization of HF and all-cause mortality during follow-up in the study population. Adjusted hazard ratios were calculated using Cox proportional hazards regression models. Linearity of the continuous variables with respect to the response variable was assessed by determining the quartiles of their distribution. If no linearity was demonstrated, the variable was further categorized, primarily the median value or on the basis of clinical relevance. All univariate predictors with P < 0.1 were tested in a multivariate model, including age, gender, NYHA class, underlying heart disease, renal function, drug therapy, and echocardiographic measurements. In the multivariate model, a variable was excluded when P ≥ 0.05. A stepwise approach was used, and first-line interactions were investigated. In all analyses, a value of P < 0.05 was considered statistically significant.


   Results
Top
 Abstract
 Introduction
 Methods and patients
 Results
Discussion
 Conclusions
 References
 
Patient characteristics
A total of 121 patients with AF were included (Table 1), 45 (37%) with a previous hospitalization for HF. Patients with a previous hospitalization for HF were older and had more severe underlying heart disease and impaired renal function (Table 1).


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  		Table 1 Patients characteristics

 
Treatment
A single-chamber VVIR pacemaker was implanted in 77 (64%), 13 patients with paroxysmal AF and 64 patients with permanent AF. In 44 (36%) patients, a DDDR pacemaker was implanted, 28 patients with paroxysmal AF and 16 patients with permanent AF (P < 0.001). Initial AV node ablation was successful in 111 (92%) patients. A second attempt for ablation was needed in 10 (8%) patients. Eventually, complete AV block was achieved in all patients. Both pacemaker implantation and AV node ablation were uneventful in all patients.

Follow-up
The mean follow-up was 4.3 ± 3.3 years. At the end of follow-up, patients treated with class I, III, and IV antiarrhythmic drug therapy had diminished (Table 2). Almost all patients (94%) used oral anticoagulation during complete follow-up. At the end of follow-up, most patients were in NYHA functional class I [43 (36%)] and II [37 (31%)], whereas only a few patients were in class III [14 (12%)] and IV [1 (1%)]. No significant changes in NYHA functional class between baseline and end of follow-up were observed (P = 0.097).


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  		Table 2 Medication during the study

 
In the total population and in patients with previous HF, the LV end systolic diameter decreased and fractional shortening improved (Table 3). Left ventricular end diastolic diameter did not change. In patients without previous HF, no changes in LV diameters and fractional shortening were observed. Left and right atrial diameters increased in all groups during follow-up (Table 3). A marked deterioration of fractional shortening was observed in six patients, all with previous HF.


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  		Table 3 Echocardiographic measurements before atrioventricular node ablation and at the end of follow-upa

 
Hospitalization for heart failure and all-cause mortality
Hospitalization for HF occurred in 24 (20%) patients, predominantly in patients with HF (n = 15, Figure 1). Multivariate regression analyses revealed previous hospitalization for HF, coronary artery disease, and male gender use as independent predictors for the occurrence of hospitalizations for HF during follow-up (Table 4). All-cause mortality occurred in 31 (26%) patients during follow-up, including cardiovascular mortality in 12 patients (10%). In patients with HF, all-cause mortality occurred in 14 patients (31%), including cardiovascular mortality in 6 patients (13%). Regression analyses revealed age > 67 years as the only predictor for all-cause mortality (Table 4).


Figure 1
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  		Figure 1 Kaplan–Meier survival curve of the time to hospitalization for heart failure in patients without and with previous hospitalization for heart failure (dotted line).

 


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  		Table 4 Independent determinants of hospitalization for heart failure and all-cause mortality over time

 
Quality of life
Fifty of the living patients filled out the SF-36 questionnaire. Comparison of these patients with an age- and sex-matched group of healthy controls revealed a comparable quality of life on seven of the eight scales. Atrioventricular node ablation patients had a higher score on the vitality scale (52 vs. 64, P = 0.048). The specific AV node ablation survey was completed by 43 patients (Table 5). The majority of the patients affirmed, in retrospect, their initial choice for catheter ablation intervention for AF and would recommend it to patients with equal complaints.


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  		Table 5 Results of atrioventricular node ablation-specific questionnaire

 

   Discussion
Top
 Abstract
 Introduction
 Methods and patients
 Results
 Discussion
Conclusions
 References
 
The present study shows that in patients with AV node ablation and pacemaker implantation, LV function and functional class do not deteriorate after long-term follow-up, even in patients with previous HF. Heart failure necessitating hospitalization, however, predominantly occurred in the latter patients.

Role of atrioventricular node ablation in 2008
Previously, AV node ablation followed by permanent right ventricular pacing was often performed in symptomatic AF patients after failure on antiarrhythmic drugs.7Go,24Go At present, AV node ablation is less frequently performed. This is caused by a high success rate of atrial ablation that cures patients from AF8Go and concerns about its safety because of its potential to induce HF.

Atrioventricular node ablation effectively controls the ventricular rate and reduces symptoms and the need for drugs.4Go–7Go,25Go However, it also has several limitations. Continuous permanent right ventricular pacing may deteriorate LV function and increase the risk on HF.11Go–13Go,26Go At least in part, this seems related to the induction of LV dyssynchrony, even in patients with initially normal LV function.14Go,15Go

Outcome in our patient population was good, both in patients with and without previous HF. There was no deterioration of LV function. Hospitalizations for HF predominantly occurred in patients previously known with HF. More than 70% of patients were still alive after a follow-up of 5 years, which is in line with the data of Oczan et al.25Go In that study, long-term survival was worse in AF patients treated with AV node ablation compared with healthy controls, but comparable with AF patients treated with drug therapy. Furthermore, the present study shows that quality of life was comparable with healthy controls at the end of follow-up.

Previous studies showed dissimilar results with regard to the outcome of cardiac function. This may be related to different patient populations, small numbers of patients, and various follow-up durations in the respective studies. Especially, studies with shorter follow-ups show an improvement of cardiac function, predominantly in patients with an impaired cardiac function at baseline.27Go,28Go Rodriguez et al.27Go showed an improvement of cardiac function in patients with lone AF, with an LV ejection fraction at baseline below 50%. Comparable results were reported by Edner et al.28Go in patients with LV dysfunction. They showed, comparable with our data, no effect on cardiac function in patients with a normal LV function. In contrast, more recent reports showed a deterioration of cardiac function after long-term follow-up, also in patients with a normal LV function at baseline.14Go,15Go,29Go Szili-Torok et al.29Go demonstrated an impairment of LV ejection fraction after a follow-up of 3 months in a mixed group of 12 patients. After a mean follow-up of 4 years, Tops et al.14Go observed the occurrence of LV dyssynchrony in 49% (n = 27) of their patients. Concurrently, these patients worsened in HF symptoms and showed an impairment of LV function. In contrast, patients who did not develop LV dyssynchrony did not deteriorate in HF symptoms, LV function, or LV volumes. Vernooy et al.15Go investigated 55 patients and reported an impairment of LV function in patients with initially normal LV function. Their group consisted of only 28 patients, their follow-up, however, was long (7 years).

The aforementioned data indicate that cardiac function may impair owing to permanent right ventricular pacing inducing LV dyssynchrony, in accordance to data on continuous pacing in patients without AV node ablation. However, as also suggested by the study of Tops et al., not every person is at risk. Ideally, patients at risk for the development of LV dyssynchrony and HF should be identified beforehand. In these patients, biventricular pacing may have beneficial effect.17Go,30Go,31Go

The value of biventricular pacing to reduce the risk on HF in these patients still remains to be proved. A recent meta-analysis of 3 randomized trials with 347 patients compared cardiac resynchronization therapy with right ventricular pacing in AF patients treated with AV nodal ablation. Patients included were both patients with permanent AF with drug refractory, severely symptomatic, and uncontrolled heart rates and patients with permanent AF in the setting of HF.17Go No differences in survival, stroke, hospitalization, exercise capacity, or healthcare costs were found. Cardiac resynchronization therapy, however, was associated with an improvement in ejection fraction in two of the three trials, predominantly in patients with permanent AF in the setting of HF.

In the present study, previous hospitalization of HF, coronary artery disease, and male gender were independent predictors of hospitalization for HF during follow-up. This suggests that progression of the underlying heart disease is a main factor in the development of HF. Nevertheless, HF also occurred in patients with a normal cardiac function at baseline.

Quality of life
At the end of follow-up, quality-of-life scores in our study population were comparable with those of age- and gender-matched healthy control groups. No difference could be demonstrated for the study population at seven of the eight subscales of the SF-36. Quality-of-life questionnaire compared with the healthy controls. This in agreement with previous AV node ablation studies.6Go Pharmacological rate-control approaches, as used in the major rate- vs. rhythm-control trials, are not able to improve quality of life of patients with permanent AF to the level of healthy controls.32Go

Limitations
The present analysis was retrospective in design and has therefore important limitations. This design in combination with the relatively small numbers of patients included precludes definite conclusions. Cause–effect relationship cannot be demonstrated and the present data are thus only hypothesis generating. Left ventricular ejection fraction measurements were not available in the majority of patients. Although the follow-up was relatively long, we cannot exclude that in our patients LV dysfunction may have been observed in case of a longer follow-up. Quality of life and the specific AV node ablation survey were not performed in all patients. A selection bias may therefore have been introduced.


   Conclusions
Top
 Abstract
 Introduction
 Methods and patients
 Results
 Discussion
 Conclusions
References
 
Our study underlines the role of AV node ablation for the treatment of AF. Long-term follow-up is good in many patients. However, HF may occur also in patients with normal cardiac function at baseline. Probably, this relates to both progression of the underlying disease and permanent right ventricular pacing. The beneficial effects of biventricular pacing seem obvious but remain to be proved. In our opinion, nowadays, candidates for AV node ablation are patients with permanent symptomatic AF and poor control of the ventricular rate despite pharmacological therapy or patients with severe adverse effects of rate-control drugs.

Conflict of interest: none declared.


   References
Top
 Abstract
 Introduction
 Methods and patients
 Results
 Discussion
 Conclusions
 References
 
[1] Van Gelder IC, Hagens VE, Bosker HA, Kingma JH, Kamp O, Kingma T, et al. A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. N Engl J Med (2002) 347:1834–40.[Abstract/Free Full Text]

[2] Wyse DG, Waldo AL, DiMarco JP, Domanski MJ, Rosenberg Y, Schron EB, et al. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med (2002) 347:1825–33.[Abstract/Free Full Text]

[3] Olshansky B, Rosenfeld LE, Warner AL, Solomon AJ, O’Neill G, Sharma A, et al. The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study: approaches to control rate in atrial fibrillation. J Am Coll Cardiol (2004) 43:1201–8.[Abstract/Free Full Text]

[4] Brignole M, Menozzi C, Gianfranchi L, Musso G, Mureddu R, Bottoni N, et al. Assessment of atrioventricular junction ablation and VVIR pacemaker versus pharmacological treatment in patients with heart failure and chronic atrial fibrillation: a randomized, controlled study. Circulation (1998) 98:953–60.[Abstract/Free Full Text]

[5] Brignole M, Gianfranchi L, Menozzi C, Alboni P, Musso G, Bongiorni MG, et al. Assessment of atrioventricular junction ablation and DDDR mode-switching pacemaker versus pharmacological treatment in patients with severely symptomatic paroxysmal atrial fibrillation: a randomized controlled study. Circulation (1997) 96:2617–24.[Abstract/Free Full Text]

[6] Kay GN, Ellenbogen KA, Giudici M, Redfield MM, Jenkins LS, Mianulli 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. APT Investigators. J Interv Card Electrophysiol (1998) 2:121–35.[CrossRef][Web of Science][Medline]

[7] Wood MA, Brown-Mahoney C, Kay GN, Ellenbogen KA. Clinical outcomes after ablation and pacing therapy for atrial fibrillation: a meta-analysis. Circulation (2000) 101:1138–44.[Abstract/Free Full Text]

[8] Calkins H, Brugada J, Packer DL, Cappato R, Chen SA, Crijns HJ, et al. HRS/EHRA/ECAS Expert Consensus Statement on catheter and surgical ablation of atrial fibrillation: recommendations for personnel, policy, procedures and follow-up. A report of the Heart Rhythm Society (HRS) Task Force on catheter and surgical ablation of atrial fibrillation. Heart Rhythm (2007) 4:816–61.[CrossRef][Web of Science][Medline]

[9] Berruezo A, Tamborero D, Mont L, Benito B, Tolosana JM, Sitges M, et al. Pre-procedural predictors of atrial fibrillation recurrence after circumferential pulmonary vein ablation. Eur Heart J (2007) 28:836–41.[Abstract/Free Full Text]

[10] Rienstra M, Van Veldhuisen DJ, Crijns HJ, Van Gelder IC. Enhanced cardiovascular morbidity and mortality during rhythm control treatment in persistent atrial fibrillation in hypertensives. Data of the RACE study. Eur Heart J (2007) 28:741–51.[Abstract/Free Full Text]

[11] Wilkoff BL, Cook JR, Epstein AE, Greene HL, Hallstrom AP, Hsia H, et al. Dual-chamber pacing or ventricular backup pacing in patients with an implantable defibrillator: the Dual Chamber and VVI Implantable Defibrillator (DAVID) Trial. JAMA (2002) 288:3115–23.[Abstract/Free Full Text]

[12] Hohnloser SH, Kuck KH, Dorian P, Roberts RS, Hampton JR, Hatala R, et al. Prophylactic use of an implantable cardioverter-defibrillator after acute myocardial infarction. N Engl J Med (2004) 351:2481–8.[Abstract/Free Full Text]

[13] Smit MD, Van Dessel PF, Nieuwland W, Wiesfeld AC, Tan ES, Anthonio RL, et al. Right ventricular pacing and the risk of heart failure in implantable cardioverter-defibrillator patients. Heart Rhythm (2006) 3:1397–403.[CrossRef][Web of Science][Medline]

[14] Tops LF, Schalij MJ, Holman ER, van Erven L, van der Wall EE, Bax JJ. Right ventricular pacing can induce ventricular dyssynchrony in patients with atrial fibrillation after atrioventricular node ablation. J Am Coll Cardiol (2006) 48:1642–8.[Abstract/Free Full Text]

[15] Vernooy K, Dijkman B, Cheriex EC, Prinzen FW, Crijns HJ. Ventricular remodeling during long-term right ventricular pacing following His bundle ablation. Am J Cardiol (2006) 97:1223–7.[CrossRef][Web of Science][Medline]

[16] Sweeney M, Bank A, Nsah E, Koullick M, Zeng Q, Hettrick D, et al. Minimizing ventricular pacing to reduce atrial fibrillation in sinus-node disease. N Engl J Med (2007) 357:1000–8.[Abstract/Free Full Text]

[17] Bradley D, Shen W. Atrioventricular junction ablation combined with either right ventricular pacing or cardiac resynchronization therapy for atrial fibrillation: the need for large-scale randomized trials. Heart Rhythm (2007) 4:224–32.[CrossRef][Web of Science][Medline]

[18] Olgin J, Scheinman M. Comparison of high energy direct current and radiofrequency catheter ablation of the atrioventricular junction. J Am Coll Cardiol (1993) 21:557–63.[Abstract]

[19] Trohman R, Simmons T, Moore S, Firstenberg M, Williams D, Maloney J. Catheter ablation of the atrioventricular junction using radiofrequency energy and a bilateral cardiac approach. Am J Cardiol (1992) 70:1438–43.[CrossRef][Web of Science][Medline]

[20] Geelen P, Brugada J, Andries E, Brugada P. Ventricular fibrillation and sudden death after radiofrequency catheter ablation of the atrioventricular junction. Pacing Clin Electrophysiol (1997) 20:343–8.[CrossRef][Medline]

[21] Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. MedCare (1992) 30:473–83.

[22] Aaronson NK, Muller M, Cohen PD, Essink-Bot ML, Fekkes M, Sanderman R, et al. Translation, validation, and norming of the Dutch language version of the SF-36 Health Survey in community and chronic disease populations. J Clin Epidemiol (1998) 51:1055–68.[CrossRef][Web of Science][Medline]

[23] Hemels ME, Gu YL, Tuinenburg AE, Boonstra PW, Wiesfeld AC, Van Den Berg MP, et al. Favorable long-term outcome of Maze surgery in patients with lone atrial fibrillation. Ann Thorac Surg (2006) 81:1773–9.[Abstract/Free Full Text]

[24] Fuster V, Ryden LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, 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 (2006) 27:1979–2030.[Free Full Text]

[25] Ozcan C, Jahangir A, Friedman P, Patel P, Munger T, Rea R, et al. Long-term survival after ablation of the atrioventricular node and implantation of a permanent pacemaker in patients with atrial fibrillation. N Engl J Med (2001) 344:1043–51.[Abstract/Free Full Text]

[26] Moss AJ, Zareba W, Hall WJ, Klein H, Wilber DJ, Cannom DS, et al. Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. N Engl J Med (2002) 346:877–83.[Abstract/Free Full Text]

[27] Rodriguez LM, Smeets JL, Xie B, de Chillou C, Cheriex E, Pieters F, et al. Improvement in left ventricular function by ablation of atrioventricular nodal conduction in selected patients with lone atrial fibrillation. Am J Cardiol (1993) 72:1137–41.[CrossRef][Web of Science][Medline]

[28] Edner M, Caidahl K, Bergfeldt L, Darpö B, Edvardsson N, Rosenqvist M. Prospective study of left ventricular function after radiofrequency ablation of atrioventricular junction in patients with atrial fibrillation. Br Heart J (1995) 74:261–7.[Abstract/Free Full Text]

[29] Szili-Torok T, Kimman G, Theuns D, Poldermans D, Roelandt J, Jordaens L. Deterioration of left ventricular function following atrio-ventricular node ablation and right ventricular apical pacing in patients with permanent atrial fibrillation. Europace (2002) 4:61–5.[Free Full Text]

[30] Doshi RN, Daoud EG, Fellows C, Turk K, Duran A, Hamdan MH, et al. Left ventricular-based cardiac stimulation post AV nodal ablation evaluation (the PAVE study). J Cardiovasc Electrophysiol (2005) 16:1160–5.[CrossRef][Web of Science][Medline]

[31] Brignole M, Gammage M, Puggioni E, Alboni P, Raviele A, Sutton R, et al. Comparative assessment of right, left, and biventricular pacing in patients with permanent atrial fibrillation. Eur Heart J (2005) 26:712–22.[Abstract/Free Full Text]

[32] Hagens VE, Ranchor AV, van Sonderen EF, Bosker HA, Kamp O, Tijssen JG, et al. Effect of rate or rhythm control on quality of life in persistent atrial fibrillation. J Am Coll Cardiol (2004) 43:241–7.[Abstract/Free Full Text]


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