Quality of life and outcomes after radiofrequency His-bundle catheter ablation and permanent pacemaker implantation: Impact of treatment in paroxysmal and established atrial fibrillation Adam P. Fitzpatrick, MD, MRCP, Hratch D. Kourouyan, BS, Andreana Siu, RN, Randall J. Lee, MD, Michael D. Lesh, MD, Laurence M. Epstein, MD, Jerry C. Griffin, MD, and Melvin M. Scheinman, MD San Francisco, Calif. One hundred seven patients underwent atrioventricular (AV)-junctional ablation and pacing for atrial fibrillation, and 90 were alive 2.3 ± 1.2 years later. Quality of life index (1.9 ± 1.2 to 3.6 ± 1.1; 3.6_ 1.1; p<0;001) and ease of activities of daily living (2 ~ 0.4 to 2.4 ± 0.3; p < 0.001) were significantly improved. Doctor visits (10 ± 13 to 5.06 ± 7; p< 0.03), hospital admissions (2.8 ± 6.8 vs 0,17 ± 0.54; p < 0.03),andantiarrhythmicdrugtrials(6.2 ± 4to0.46 ± 1.5; p < 0.001) decreased significantly after treatment. Conges- tive heart failure episodes decreased from 18 before to 8 af- terward. Twenty-eight of 36 patients with dual-chamber pacemakers remained in a dual-chamber mode at follow-up, Radiofrequency AV-junctional catheter ablation and pacing is a highly successful form of treatment for medically refractory atrial fibrillation. (AM HEART J 1996;131:499-507.) There is increasing interest in nonpharmacologic treatment of atrial fibrillation (AF). Many authors have shown that patients with AF may develop im- pairment of left ventricular function partly or largely as a result of AF itself, rather than because of underlying heart disease, because of the improve- ment seen after return of sinus rhythm, or control of heart rate and rhythm after atrioventricular junc- tion (AVJ) ablation and permanent pacing. 1-7 This impairment of ventricular function may be a form of tachycardic cardiomyopathy. This phenomenon has been reported in patients with supraventricular ta- chycardias related to the presence of an accessory atrioventricular pathway causing the permanent form ofjunctional reciprocating tachycardia, s or with From the University of California and CVRI. Received for publication June 12, 1995; accepted July 20, 1995. Reprint requests: Adam P. Fitzpatrick, MD, MRCP, Manchester Heart Centre, Manchester Royal Infirmary, Oxford Rd., Manchester M13 9WL, UK. Copyright © 1996 by Mosby-Year Book, Inc. 0002-8703/96/$5.00 + 0 4/1/68625 automatic atrial tachycardias. 9 Relief from the ta- chycardia with improvement of ventricular function suggests a deleterious effect of long-term rapid heart rates. Treatment by AVJ ablation and pacing may bring benefits from regularization of heart rhythm, as well as from control of rapid ventricular rates. A number of reports have shown improvement in left ventricular function with control of heart rate by pharmacologic means by using drugs that suppress conduction through the atrioventricular node and also with catheter ablation of the AVJ. 4"7 Some lim- ited reports have also highlighted gains in terms of quality of life. 5, 10-11 At the same time, other authors have reported apparently deleterious effects of anti- arrhythmic medication in AF, 12, 13 and also poten- tially harmful effects on short-term and long-term survival of direct current (DC) ablation, 5, 10, 14, 15 commonly used until the advent of catheter ablation by radiofrequency energy. Radiofrequency (RF) tech- niques have a success rate equivalent to that of direct current application without the potentially harmful barotrauma of high-voltage discharges. 4, 5 We previ- ously addressed the issue of outcome after AVJ ab- lation in patients treated exclusively with DC abla- tion 5 and in a smaller group treated by RF catheter ablation. 1° Since compiling these reports, our expe- rience with RF energy has increased, and follow-up has extended. We therefore had the opportunity to review a large series of patients treated without the significant early and late complications associated with DC discharges. 5, 14 RF catheter ablation of the AVJ should maximize the benefit of nonpharmaco- logic rate and rhythm control, potentially widening the scope of this form of treatment. Many patients with persistent symptoms and impaired quality of life might be considered for catheter ablation at an earlier stage after fewer drug trials. We had a large 499