https://doi.org/10.1007/s00392-024-02526-y
1Deutsches Herzzentrum der Charite (DHZC) Klinik für Kardiologie, Angiologie und Intensivmedizin | CBF Berlin, Deutschland; 2Vivantes Auguste-Viktoria-Klinikum Klinik für Innere Medizin/Kardiologie Berlin, Deutschland
Atrial fibrillation (AF) can lead to symptomatic bradycardia and pre-automatic pauses, a subtype of sick sinus syndrome. Treatment of AF with catheter ablation may prevent recurrence through maintaining sinus rhythm or maybe also due to autonomic modulation. The current ESC guidelines from 2020 and the 2024 EHRA expert consensus statement recommend catheter ablation (CA) as an alternative strategy to avoid pacemaker implantation in selected cases (Class IIA, Level C). Data to support this strategy is derived from two trials published in 2014. Both used both clinical and holter ECG follow up.
We report a case series where this treatment approach was applied and follow up using internal loop recorders was available.
Methods:
Consecutive patients who met the following strict inclusion criteria were retrospectively identified: (a) CA of paroxysmal or persistent AF (b) initial diagnosis of symptomatic (presyncope or syncope) sick sinus syndrome (c) no further indication for pacemaker implantation and (d) implantation of a loop recorder (ILR).
After CA und ILR implantation, patients were included in our home monitoring system to enable continuous follow-up.
Results:
In total, eleven patients were identified. Seven patients (64%) had preautomatic pauses with a mean duration of 6,2 ms (+ 4,1) (see table 1 and 2), four patients had symptomatic (sinus-) bradycardia. CA was successfully performed in all patients.
After a mean follow-up of six months, 8/11 patients (73%) remained in sinus rhythm with no more symptomatic episodes of sick sinus syndrome.
Three patients required permanent pacemaker implantation. The first patient had continuous severe sick sinus syndrome, and pacemaker implantation had to be performed shortly after (six days) CA. In the two other patients, sinus rhythm could not be established after the first ablation procedure, and symptomatic preautomatic pauses reoccurred. Pacemaker implantation was performed 57 and 91 days after the initial ablation, considering the clinical situation and the patients preference.
Conclusion:
In the majority of patients (73%) presenting with symptomatic sick sinus syndrome and AF, CA was able to prevent the need for pacemaker implantation. Continuous follow-up is recommended to screen for further episodes of symptomatic bradycardia.
Table 1: Patient characteristics
|
Age (years, mean+SD) |
BMI (kg/m2, mean+SD) |
Female, n (%) |
LVEF (%; median; IQR) |
|
76 + 6 |
26,8 + 6,5 |
7 (64) |
55 (48– 59) |
|
Coronary heart disease, n (%) |
COPD, n (%) |
DMT II, n (%) |
CHADS-Vasc (mean+SD) |
|
6 (54) |
2 (18) |
3 (27) |
3,6 + 3,6 |
|
Left atrial volume index (ml/m2) |
Paroxysmal atrial fibrillation, n (%) |
Left atrial volume index (ml/m2) |
Paroxysmal atrial fibrillation, n (%) |
|
38,1 + 8,6 |
8 (73%) |
38,1 + 8,6 |
8 (73%) |
Table 2: Ablation and electrocardiographic characteristics
|
First CA, n (%) |
PFA/Cryo, n (%) |
RFA, n (%) |
LVA > 35%, n (%) |
|
10 (91) |
2 (18) / 1 (9) |
8 (73) |
2 (20) |
|
QRS-duration (ms, mean+SD) |
PQ-intervall (ms, mean+SD) |
Atrial and ventricular pacing in case of pacemaker implantation |
QRS-duration (ms, mean+SD) |
|
93,8 + 17,3 |
169,5 + 21,6 |
(75/0%; 0/0,5%; 36/0%) |
93,8 + 17,3 |