Ablate and pace for drug refractory paroxysmal atrial fibrillation. Is ablation necessary?

Atrio-ventricular junctional ablation with pacemaker insertion has been shown to improve quality of life in patients with drug refractory paroxysmal atrial fibrillation. It is unknown whether this improvement is secondary to the ablation procedure or to the pacemaker mode utilised. To investigate this we reviewed our experience of implanting a dual chamber rate responsive pacemaker with mode switching (DDDR/MS) alone on quality of life in this patient group.

Over a 1-year period, 19 patients (mean age 62+/-9 years, 13 female) with drug refractory paroxysmal atrial fibrillation (mean duration of symptoms 8.7+/-7 years, failed 3.1+/-0.9 anti-arrhythmic drugs, amiodarone in 15) were recruited. Quality of life was assessed at baseline and after 1 month using a cardiac specific questionnaire, the modified Karolinska questionnaire. The mean score for all patients significantly improved by 39% at follow up (baseline 59+/-24, 1 month 36+/-24, P=0.001). Individually 15 patients (79%) had an improvement in their score, whilst for 13 patients (68%) their symptoms were sufficiently improved after pacing that ablation was not required. The benefit was maintained to a mean follow up of 12+/-5 months (score 31+/-20, P<0.001). Six patients remained symptomatic after pacing and requested further treatment. Benefit was unrelated to symptoms at baseline or the number and total duration of paroxysmal atrial fibrillation episodes recorded on pacemaker Holter.

Patients with drug refractory paroxysmal atrial fibrillation, DDDR/MS pacing alone can improve quality of life without concurrent atrio-ventricular junctional ablation in a significant proportion of patients.