Control of ventricular rate in atrial fibrillation: Nonpharmacologic therapy
- Leonard I Ganz, MD, FHRS, FACC
Leonard I Ganz, MD, FHRS, FACC
- Section Editor — Cardiac Arrhythmias
- Director of Cardiac Electrophysiology
- Heritage Valley Health System
In patients with atrial fibrillation (AF), the ventricular rate is controlled by the conduction properties of the atrioventricular node. In the typical patient with untreated AF, the ventricular rate can reach 150 beats/min or higher.
There are two important reasons to prevent a rapid ventricular response in patients with AF:
●Avoidance of hemodynamic instability and/or symptoms. (See "Hemodynamic consequences of atrial fibrillation and cardioversion to sinus rhythm".)
●Avoidance of a tachycardia-mediated cardiomyopathy. (See "Arrhythmia-induced cardiomyopathy".)
In patients with AF, a rapid ventricular response can be prevented either by restoring sinus rhythm or with therapies that reduce the ventricular response to AF. When rate control is chosen, it can usually be accomplished with pharmacologic therapy. However, some AF patients will respond poorly to or be intolerant of rate control medications. Options for such patients include reconsideration of a rhythm control strategy and nonpharmacologic methods to control the ventricular rate. (See "Overview of atrial fibrillation" and "Rhythm control versus rate control in atrial fibrillation".)
- Fuster V, Ryden LE, Cannom DS, et al. ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation). J Am Coll Cardiol. 2006; 48:e149.
- Rosenquvist M, Lee MA, Moulinier L, et al. Long-term follow-up of patients after transcatheter direct current ablation of the atrioventricular junction. J Am Coll Cardiol 1990; 16:1467.
- Curtis AB, Kutalek SP, Prior M, Newhouse TT. Prevalence and characteristics of escape rhythms after radiofrequency ablation of the atrioventricular junction: results from the registry for AV junction ablation and pacing in atrial fibrillation. Ablate and Pace Trial Investigators. Am Heart J 2000; 139:122.
- Scheinman MM, Huang S. The 1998 NASPE prospective catheter ablation registry. Pacing Clin Electrophysiol 2000; 23:1020.
- Fitzpatrick AP, Kourouyan HD, Siu A, et al. Quality of life and outcomes after radiofrequency His-bundle catheter ablation and permanent pacemaker implantation: impact of treatment in paroxysmal and established atrial fibrillation. Am Heart J 1996; 131:499.
- Wood MA, Brown-Mahoney C, Kay GN, Ellenbogen KA. Clinical outcomes after ablation and pacing therapy for atrial fibrillation : a meta-analysis. Circulation 2000; 101:1138.
- Brown CS, Mills RM Jr, Conti JB, Curtis AB. Clinical improvement after atrioventricular nodal ablation for atrial fibrillation does not correlate with improved ejection fraction. Am J Cardiol 1997; 80:1090.
- Weerasooriya R, Davis M, Powell A, et al. The Australian Intervention Randomized Control of Rate in Atrial Fibrillation Trial (AIRCRAFT). J Am Coll Cardiol 2003; 41:1697.
- Ozcan C, Jahangir A, Friedman PA, et al. Long-term survival after ablation of the atrioventricular node and implantation of a permanent pacemaker in patients with atrial fibrillation. N Engl J Med 2001; 344:1043.
- Marshall HJ, Harris ZI, Griffith MJ, et al. Prospective randomized study of ablation and pacing versus medical therapy for paroxysmal atrial fibrillation: effects of pacing mode and mode-switch algorithm. Circulation 1999; 99:1587.
- Kamalvand K, Tan K, Kotsakis A, et al. Is mode switching beneficial? A randomized study in patients with paroxysmal atrial tachyarrhythmias. J Am Coll Cardiol 1997; 30:496.
- Gribbin GM, Bourke JP, McComb JM. Predictors of atrial rhythm after atrioventricular node ablation for the treatment of paroxysmal atrial arrhythmias. Heart 1998; 79:548.
- Gillis AM, Connolly SJ, Lacombe P, et al. Randomized crossover comparison of DDDR versus VDD pacing after atrioventricular junction ablation for prevention of atrial fibrillation. The atrial pacing peri-ablation for paroxysmal atrial fibrillation (PA (3)) study investigators. Circulation 2000; 102:736.
- Ozcan C, Jahangir A, Friedman PA, et al. Sudden death after radiofrequency ablation of the atrioventricular node in patients with atrial fibrillation. J Am Coll Cardiol 2002; 40:105.
- Hamdan MH, Page RL, Sheehan CJ, et al. Increased sympathetic activity after atrioventricular junction ablation in patients with chronic atrial fibrillation. J Am Coll Cardiol 2000; 36:151.
- Geelen P, Brugada J, Andries E, Brugada P. Ventricular fibrillation and sudden death after radiofrequency catheter ablation of the atrioventricular junction. Pacing Clin Electrophysiol 1997; 20:343.
- Gasparini M, Mantica M, Brignole M, et al. Thromboembolism after atrioventricular node ablation and pacing: long term follow up. Heart 1999; 82:494.
- Williamson BD, Man KC, Daoud E, et al. Radiofrequency catheter modification of atrioventricular conduction to control the ventricular rate during atrial fibrillation. N Engl J Med 1994; 331:910.
- Canby RC, Román CA, Kessler DJ, et al. Selective radiofrequency ablation of the "slow" atrioventricular nodal pathway for control of the ventricular response to atrial fibrillation. Am J Cardiol 1996; 77:1358.
- Della Bella P, Carbucicchio C, Tondo C, Riva S. Modulation of atrioventricular conduction by ablation of the "slow" atrioventricular node pathway in patients with drug-refractory atrial fibrillation or flutter. J Am Coll Cardiol 1995; 25:39.
- Kreiner G, Heinz G, Siostrzonek P, Gössinger HD. Effect of slow pathway ablation on ventricular rate during atrial fibrillation. Dependence on electrophysiological properties of the fast pathway. Circulation 1996; 93:277.
- Strickberger SA, Weiss R, Daoud EG, et al. Ventricular rate during atrial fibrillation before and after slow-pathway ablation. Effects of autonomic blockade and beta-adrenergic stimulation. Circulation 1996; 94:1023.
- Proclemer A, Della Bella P, Tondo C, et al. Radiofrequency ablation of atrioventricular junction and pacemaker implantation versus modulation of atrioventricular conduction in drug refractory atrial fibrillation. Am J Cardiol 1999; 83:1437.
- Twidale N, McDonald T, Nave K, Seal A. Comparison of the effects of AV nodal ablation versus AV nodal modification in patients with congestive heart failure and uncontrolled atrial fibrillation. Pacing Clin Electrophysiol 1998; 21:641.
- Occhetta E, Bortnik M, Magnani A, et al. Prevention of ventricular desynchronization by permanent para-Hisian pacing after atrioventricular node ablation in chronic atrial fibrillation: a crossover, blinded, randomized study versus apical right ventricular pacing. J Am Coll Cardiol 2006; 47:1938.
- Lü F, Iaizzo PA, Benditt DG, et al. Isolated atrial segment pacing: an alternative to His bundle pacing after atrioventricular junctional ablation. J Am Coll Cardiol 2007; 49:1443.
- Wood MA. Trials of pacing to control ventricular rate during atrial fibrillation. J Interv Card Electrophysiol 2004; 10 Suppl 1:63.
- Donahue JK, Heldman AW, Fraser H, et al. Focal modification of electrical conduction in the heart by viral gene transfer. Nat Med 2000; 6:1395.
- Wann LS, Curtis AB, January CT, et al. 2011 ACCF/AHA/HRS focused update on the management of patients with atrial fibrillation (updating the 2006 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011; 123:104.
- American College of Cardiology Foundation, American Heart Association, European Society of Cardiology, et al. Management of patients with atrial fibrillation (compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. Circulation 2013; 127:1916.
- GENERAL PRINCIPLES
- Determinants of ventricular rate
- Adequacy of rate control
- AV NODAL ABLATION
- Outcomes and quality of life
- Pacemaker selection
- - Single chamber ventricular pacemaker
- - Dual chamber pacemaker
- - Cardiac resynchronization therapy
- - Implantable cardioverter-defibrillators
- Postablation risk of VF and pacing rates
- Need for anticoagulation
- AV NODAL CONDUCTION MODIFICATION
- INVESTIGATIONAL METHODS
- Para-Hisian pacing
- Low atrial isolation
- Ventricular rate regularization
- Gene therapy
- SUMMARY AND RECOMMENDATIONS