A roadmap to improve the quality of atrial fibrillation management: proceedings from the fifth Atrial Fibrillation Network/European Heart Rhythm Association consensus conference.

At least 30 million people worldwide carry a diagnosis of atrial fibrillation (AF), and many more suffer from undiagnosed, subclinical, or 'silent' AF. Atrial fibrillation-related cardiovascular mortality and morbidity, including cardiovascular deaths, heart failure, stroke, and hospitalizations, remain unacceptably high, even when evidence-based therapies such as anticoagulation and rate control are used. Furthermore, it is still necessary to define how best to prevent AF, largely due to a lack of clinical measures that would allow identification of treatable causes of AF in any given patient. Hence, there are important unmet clinical and research needs in the evaluation and management of AF patients. The ensuing needs and opportunities for improving the quality of AF care were discussed during the fifth Atrial Fibrillation Network/European Heart Rhythm Association consensus conference in Nice, France, on 22 and 23 January 2015. Here, we report the outcome of this conference, with a focus on (i) learning from our 'neighbours' to improve AF care, (ii) patient-centred approaches to AF management, (iii) structured care of AF patients, (iv) improving the quality of AF treatment, and (v) personalization of AF management. This report ends with a list of priorities for research in AF patients.

Right atrial preventive and antitachycardia pacing for prevention of paroxysmal atrial fibrillation in patients without bradycardia: a randomized study.

AIMS: To investigate the efficacy of preventive and antitachycardia pacing (ATP) in patients with symptomatic paroxysmal atrial fibrillation (AF) without bradyarrhythmias. METHODS AND RESULTS: In this randomized cross-over pilot study, we randomized 38 symptomatic paroxysmal AF patients 'without' bradyarrhythmias to atrial pacing lower rate 70 ppm and prevention and ATP therapies ON or to atrial pacing lower rate 34 ppm and prevention and ATP therapies OFF during 12 weeks with a 4 week washout period in between. The atrial lead was preferably placed in the inter-atrial septum. Antiarrhythmic drugs were continued during the study. Primary endpoint was AF burden. Mean age was 62 +/- 9 years and 27 (71%) patients had lone AF. Septal lead placement was accomplished in 26 (68%) patients. During the treatment ON, there was a trend for AF burden reduction [from median 3.3% (1.0-15.2) to 2.4% (0.2-12.2), P = 0.06, reduction 27%]. If septal lead placement was accomplished, AF burden reduction was statistically significant [44% reduction, from median 2.5% (1.0-8.0) to 1.4% (0.2-8.4), P = 0.03]. Quality of life and symptoms did not change, also not in the septal group. CONCLUSION: A hybrid therapy of preventive and ATP pacing and antiarrhythmic drugs may significantly reduce but not abolish AF burden if septal pacing is realized.

Morphology of the RV electrogram during LV pacing is related to the hemodynamic effect in cardiac resynchronization therapy.

BACKGROUND: Biventricular (BiV) pacing and left ventricular (LV) pacing both improve LV function in patients with heart failure and LV dyssynchrony. We studied the hemodynamic effect of the atrioventricular (AV) interval and the associated changes in the right ventricular (RV) electrogram (EGM) during LV pacing and compared this with the hemodynamic effect of optimized sequential BiV pacing. METHODS: In 16 patients with New York Heart Association (NYHA) class II to IV, sinus rhythm with normal AV conduction, left bundle branch block (LBBB), QRS > 130 ms, and optimal medical therapy, the changes in RV EGM during LV pacing with varying AV intervals were studied. The hemodynamic effect associated with these changes was evaluated by invasive measurement of LVdP/dt(max) and compared with the result of optimized sequential BiV pacing in the same patient. RESULTS: All patients showed electrocardiographic fusion during LV pacing. The morphology of the RV EGM showed changes in the RV activation that indicated a shift in the extent of fusion from LV pacing. These changes were associated with significant changes in LVdP/dt(max). Baseline LV dP/dt(max) was 734 +/- 177 mmHg/s, which increased to 927 +/- 202 mmHg/s (P<0.0001) with optimized LV pacing and to 920 +/- 209 mmHg/s (P<0.0001) with optimized sequential BiV pacing. CONCLUSION: The RV EGM is a proper indicator for intrinsic activation over the right bundle during LV pacing and reveals the transition to fusion in the RV EGM that is associated with a decrease in LVdP/dt(max). The hemodynamic effect of optimized LV pacing is equal to optimized sequential BiV pacing.