Catheter Ablation Versus Medical Rate Control in Atrial Fibrillation and Systolic Dysfunction: The CAMERA-MRI Study.

Autor:	Prabhu S; The Baker Heart & Diabetes Institute, Clinical Electrophysiology Research, Melbourne, Australia; The Heart Centre, The Alfred Hospital, Melbourne, Australia; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia., Taylor AJ; The Baker Heart & Diabetes Institute, Clinical Electrophysiology Research, Melbourne, Australia; The Heart Centre, The Alfred Hospital, Melbourne, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia., Costello BT; The Baker Heart & Diabetes Institute, Clinical Electrophysiology Research, Melbourne, Australia; The Heart Centre, The Alfred Hospital, Melbourne, Australia., Kaye DM; The Baker Heart & Diabetes Institute, Clinical Electrophysiology Research, Melbourne, Australia; The Heart Centre, The Alfred Hospital, Melbourne, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia., McLellan AJA; The Baker Heart & Diabetes Institute, Clinical Electrophysiology Research, Melbourne, Australia; The Heart Centre, The Alfred Hospital, Melbourne, Australia; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia., Voskoboinik A; The Baker Heart & Diabetes Institute, Clinical Electrophysiology Research, Melbourne, Australia; The Heart Centre, The Alfred Hospital, Melbourne, Australia; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia., Sugumar H; The Baker Heart & Diabetes Institute, Clinical Electrophysiology Research, Melbourne, Australia; The Heart Centre, The Alfred Hospital, Melbourne, Australia; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia., Lockwood SM; MonashHeart, Monash Medical Centre, Melbourne, Australia., Stokes MB; MonashHeart, Monash Medical Centre, Melbourne, Australia., Pathik B; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia., Nalliah CJ; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia., Wong GR; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia., Azzopardi SM; The Baker Heart & Diabetes Institute, Clinical Electrophysiology Research, Melbourne, Australia; The Heart Centre, The Alfred Hospital, Melbourne, Australia., Gutman SJ; The Baker Heart & Diabetes Institute, Clinical Electrophysiology Research, Melbourne, Australia; The Heart Centre, The Alfred Hospital, Melbourne, Australia., Lee G; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia., Layland J; Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia., Mariani JA; The Baker Heart & Diabetes Institute, Clinical Electrophysiology Research, Melbourne, Australia; The Heart Centre, The Alfred Hospital, Melbourne, Australia; Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia., Ling LH; The Baker Heart & Diabetes Institute, Clinical Electrophysiology Research, Melbourne, Australia; The Heart Centre, The Alfred Hospital, Melbourne, Australia; Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia., Kalman JM; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia., Kistler PM; The Baker Heart & Diabetes Institute, Clinical Electrophysiology Research, Melbourne, Australia; The Heart Centre, The Alfred Hospital, Melbourne, Australia; Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia. Electronic address: peter.kistler@baker.edu.au.
Jazyk:	angličtina
Zdroj:	Journal of the American College of Cardiology [J Am Coll Cardiol] 2017 Oct 17; Vol. 70 (16), pp. 1949-1961. Date of Electronic Publication: 2017 Aug 27.
DOI:	10.1016/j.jacc.2017.08.041
Abstrakt:	Background: Atrial fibrillation (AF) and left ventricular systolic dysfunction (LVSD) frequently co-exist despite adequate rate control. Existing randomized studies of AF and LVSD of varying etiologies have reported modest benefits with a rhythm control strategy. Objectives: The goal of this study was to determine whether catheter ablation (CA) for AF could improve LVSD compared with medical rate control (MRC) where the etiology of the LVSD was unexplained, apart from the presence of AF. Methods: This multicenter, randomized clinical trial enrolled patients with persistent AF and idiopathic cardiomyopathy (left ventricular ejection fraction [LVEF] ≤45%). After optimization of rate control, patients underwent cardiac magnetic resonance (CMR) to assess LVEF and late gadolinium enhancement, indicative of ventricular fibrosis, before randomization to either CA or ongoing MRC. CA included pulmonary vein isolation and posterior wall isolation. AF burden post-CA was assessed by using an implanted loop recorder, and adequacy of MRC was assessed by using serial Holter monitoring. The primary endpoint was change in LVEF on repeat CMR at 6 months. Results: A total of 301 patients were screened; 68 patients were enrolled between November 2013 and October 2016 and randomized with 33 in each arm (accounting for 2 dropouts). The average AF burden post-CA was 1.6 ± 5.0% at 6 months. In the intention-to-treat analysis, absolute LVEF improved by 18 ± 13% in the CA group compared with 4.4 ± 13% in the MRC group (p < 0.0001) and normalized (LVEF ≥50%) in 58% versus 9% (p = 0.0002). In those undergoing CA, the absence of late gadolinium enhancement predicted greater improvements in absolute LVEF (10.7%; p = 0.0069) and normalization at 6 months (73% vs. 29%; p = 0.0093). Conclusions: AF is an underappreciated reversible cause of LVSD in this population despite adequate rate control. The restoration of sinus rhythm with CA results in significant improvements in ventricular function, particularly in the absence of ventricular fibrosis on CMR. This outcome challenges the current treatment paradigm that rate control is the appropriate strategy in patients with AF and LVSD. (Catheter Ablation Versus Medical Rate Control in Atrial Fibrillation and Systolic Dysfunction [CAMERA-MRI]; ACTRN12613000880741). (Copyright © 2017 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)
Databáze:	MEDLINE
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