363Long-term outcome of pulmonary vein isolation versus amiodarone therapy in patients with coexistent persistent atrial fibrillation and congestive heart failure

Abstract

Background: Pulmonary vein isolation (PVI) is known to have limited success rate in persistent atrial fibrillation (PerAF) patients. On the contrary, several trials on rhythm‐control drugs have shown amiodarone to be safe and effective in achieving sinus rhythm in PerAF. Objective: We evaluated the long‐term therapeutic outcome of PVI only vs amiodarone in participants of the AATAC trial with coexistent PerAF and heart failure (HF). Methods: In the AATAC trial, PerAF patients with LVEF <40% and implanted device were randomly assigned (1:1) to catheter ablation (CA) or amio arm. In the CA arm patients received PVI only or PVI plus posterior wall isolation (PWI). In the amio‐group, patients were kept on the maintenance dose of amiodarone 200 mg/day. Arrhythmia recurrence was evaluated using interrogation of implanted devices at 3, 6, 12 and 24 months post‐ablation. Results: A total of 101 and 102 patients were included in the amio and CA group respectively. Of the 102 patients in the CA group, 22 received PVI‐only and the remaining 80 patients underwent PVI + PWI. Baseline characteristics were comparable between the groups (age 62±10 vs 60±11, male 75% vs 73%, AF duration 8.6±3.2 vs 8.4±4.1 months in the CA and amio‐group) excepting BMI, which was higher in the CA group (30±8 vs 29±4, p<0.001). At the end of 4 years of follow‐up, superior success rate was observed in patients receiving CA vs amiodarone (49 (48%) vs 30 (30%), p=0.007). When stratified by ablation type, PVI‐only had significantly lower success rate than the PVI+PWI group (47 (58%) vs 2 (9%), p<0.001) as well as the amio‐group [30 (30%) vs 2 (9%), p=0.042] Conclusion: Long‐term follow‐up of the AATAC population revealed PVI+PWI ablation to have significantly higher success rate than the PVI‐only and the amiodarone group. Also of note, the outcome of the PVI‐only group was worse than the amio‐cohort at 4 years. Thus, operators should think beyond the PVs and consider adjunctive approaches to improve the ablation‐success in this subset of AF patients.