Catheter Ablation Versus Medical Rate Control in Atrial Fibrillation and Systolic Dysfunction

The CAMERA-MRI Study

Sandeep Prabhu, Andrew J. Taylor, Ben T. Costello, David M. Kaye, Alex J.A. McLellan, Aleksandr Voskoboinik, Hariharan Sugumar, Siobhan M. Lockwood, Michael B. Stokes, Bhupesh Pathik, Chrishan J. Nalliah, Geoff R. Wong, Sonia M. Azzopardi, Sarah J. Gutman, Geoffrey Lee, Jamie Layland, Justin A. Mariani, Liang han Ling, Jonathan M. Kalman, Peter M. Kistler

Research output: Contribution to journalArticleResearchpeer-review

117 Citations (Scopus)

Abstract

Background Atrial fibrillation (AF) and left ventricular systolic dysfunction (LVSD) frequently co-exist despite adequate rate control. Existing randomized studies of AF and LVSD of varying etiologies have reported modest benefits with a rhythm control strategy. Objectives The goal of this study was to determine whether catheter ablation (CA) for AF could improve LVSD compared with medical rate control (MRC) where the etiology of the LVSD was unexplained, apart from the presence of AF. Methods This multicenter, randomized clinical trial enrolled patients with persistent AF and idiopathic cardiomyopathy (left ventricular ejection fraction [LVEF] ≤45%). After optimization of rate control, patients underwent cardiac magnetic resonance (CMR) to assess LVEF and late gadolinium enhancement, indicative of ventricular fibrosis, before randomization to either CA or ongoing MRC. CA included pulmonary vein isolation and posterior wall isolation. AF burden post-CA was assessed by using an implanted loop recorder, and adequacy of MRC was assessed by using serial Holter monitoring. The primary endpoint was change in LVEF on repeat CMR at 6 months. Results A total of 301 patients were screened; 68 patients were enrolled between November 2013 and October 2016 and randomized with 33 in each arm (accounting for 2 dropouts). The average AF burden post-CA was 1.6 ± 5.0% at 6 months. In the intention-to-treat analysis, absolute LVEF improved by 18 ± 13% in the CA group compared with 4.4 ± 13% in the MRC group (p < 0.0001) and normalized (LVEF ≥50%) in 58% versus 9% (p = 0.0002). In those undergoing CA, the absence of late gadolinium enhancement predicted greater improvements in absolute LVEF (10.7%; p = 0.0069) and normalization at 6 months (73% vs. 29%; p = 0.0093). Conclusions AF is an underappreciated reversible cause of LVSD in this population despite adequate rate control. The restoration of sinus rhythm with CA results in significant improvements in ventricular function, particularly in the absence of ventricular fibrosis on CMR. This outcome challenges the current treatment paradigm that rate control is the appropriate strategy in patients with AF and LVSD. (Catheter Ablation Versus Medical Rate Control in Atrial Fibrillation and Systolic Dysfunction [CAMERA-MRI]; ACTRN12613000880741)

Original languageEnglish
Pages (from-to)1949-1961
Number of pages13
JournalJournal of the American College of Cardiology
Volume70
Issue number16
DOIs
Publication statusPublished - 17 Oct 2017

Keywords

  • catheter ablation
  • idiopathic cardiomyopathy
  • late gadolinium enhancement
  • medical rate control
  • persistent AF

Cite this

Prabhu, Sandeep ; Taylor, Andrew J. ; Costello, Ben T. ; Kaye, David M. ; McLellan, Alex J.A. ; Voskoboinik, Aleksandr ; Sugumar, Hariharan ; Lockwood, Siobhan M. ; Stokes, Michael B. ; Pathik, Bhupesh ; Nalliah, Chrishan J. ; Wong, Geoff R. ; Azzopardi, Sonia M. ; Gutman, Sarah J. ; Lee, Geoffrey ; Layland, Jamie ; Mariani, Justin A. ; Ling, Liang han ; Kalman, Jonathan M. ; Kistler, Peter M. / Catheter Ablation Versus Medical Rate Control in Atrial Fibrillation and Systolic Dysfunction : The CAMERA-MRI Study. In: Journal of the American College of Cardiology. 2017 ; Vol. 70, No. 16. pp. 1949-1961.
@article{22b6705ad9a541c19bcc26608d735654,
title = "Catheter Ablation Versus Medical Rate Control in Atrial Fibrillation and Systolic Dysfunction: The CAMERA-MRI Study",
abstract = "Background Atrial fibrillation (AF) and left ventricular systolic dysfunction (LVSD) frequently co-exist despite adequate rate control. Existing randomized studies of AF and LVSD of varying etiologies have reported modest benefits with a rhythm control strategy. Objectives The goal of this study was to determine whether catheter ablation (CA) for AF could improve LVSD compared with medical rate control (MRC) where the etiology of the LVSD was unexplained, apart from the presence of AF. Methods This multicenter, randomized clinical trial enrolled patients with persistent AF and idiopathic cardiomyopathy (left ventricular ejection fraction [LVEF] ≤45{\%}). After optimization of rate control, patients underwent cardiac magnetic resonance (CMR) to assess LVEF and late gadolinium enhancement, indicative of ventricular fibrosis, before randomization to either CA or ongoing MRC. CA included pulmonary vein isolation and posterior wall isolation. AF burden post-CA was assessed by using an implanted loop recorder, and adequacy of MRC was assessed by using serial Holter monitoring. The primary endpoint was change in LVEF on repeat CMR at 6 months. Results A total of 301 patients were screened; 68 patients were enrolled between November 2013 and October 2016 and randomized with 33 in each arm (accounting for 2 dropouts). The average AF burden post-CA was 1.6 ± 5.0{\%} at 6 months. In the intention-to-treat analysis, absolute LVEF improved by 18 ± 13{\%} in the CA group compared with 4.4 ± 13{\%} in the MRC group (p < 0.0001) and normalized (LVEF ≥50{\%}) in 58{\%} versus 9{\%} (p = 0.0002). In those undergoing CA, the absence of late gadolinium enhancement predicted greater improvements in absolute LVEF (10.7{\%}; p = 0.0069) and normalization at 6 months (73{\%} vs. 29{\%}; p = 0.0093). Conclusions AF is an underappreciated reversible cause of LVSD in this population despite adequate rate control. The restoration of sinus rhythm with CA results in significant improvements in ventricular function, particularly in the absence of ventricular fibrosis on CMR. This outcome challenges the current treatment paradigm that rate control is the appropriate strategy in patients with AF and LVSD. (Catheter Ablation Versus Medical Rate Control in Atrial Fibrillation and Systolic Dysfunction [CAMERA-MRI]; ACTRN12613000880741)",
keywords = "catheter ablation, idiopathic cardiomyopathy, late gadolinium enhancement, medical rate control, persistent AF",
author = "Sandeep Prabhu and Taylor, {Andrew J.} and Costello, {Ben T.} and Kaye, {David M.} and McLellan, {Alex J.A.} and Aleksandr Voskoboinik and Hariharan Sugumar and Lockwood, {Siobhan M.} and Stokes, {Michael B.} and Bhupesh Pathik and Nalliah, {Chrishan J.} and Wong, {Geoff R.} and Azzopardi, {Sonia M.} and Gutman, {Sarah J.} and Geoffrey Lee and Jamie Layland and Mariani, {Justin A.} and Ling, {Liang han} and Kalman, {Jonathan M.} and Kistler, {Peter M.}",
year = "2017",
month = "10",
day = "17",
doi = "10.1016/j.jacc.2017.08.041",
language = "English",
volume = "70",
pages = "1949--1961",
journal = "Journal of the American College of Cardiology",
issn = "0735-1097",
publisher = "Elsevier",
number = "16",

}

Prabhu, S, Taylor, AJ, Costello, BT, Kaye, DM, McLellan, AJA, Voskoboinik, A, Sugumar, H, Lockwood, SM, Stokes, MB, Pathik, B, Nalliah, CJ, Wong, GR, Azzopardi, SM, Gutman, SJ, Lee, G, Layland, J, Mariani, JA, Ling, LH, Kalman, JM & Kistler, PM 2017, 'Catheter Ablation Versus Medical Rate Control in Atrial Fibrillation and Systolic Dysfunction: The CAMERA-MRI Study', Journal of the American College of Cardiology, vol. 70, no. 16, pp. 1949-1961. https://doi.org/10.1016/j.jacc.2017.08.041

Catheter Ablation Versus Medical Rate Control in Atrial Fibrillation and Systolic Dysfunction : The CAMERA-MRI Study. / Prabhu, Sandeep; Taylor, Andrew J.; Costello, Ben T.; Kaye, David M.; McLellan, Alex J.A.; Voskoboinik, Aleksandr; Sugumar, Hariharan; Lockwood, Siobhan M.; Stokes, Michael B.; Pathik, Bhupesh; Nalliah, Chrishan J.; Wong, Geoff R.; Azzopardi, Sonia M.; Gutman, Sarah J.; Lee, Geoffrey; Layland, Jamie; Mariani, Justin A.; Ling, Liang han; Kalman, Jonathan M.; Kistler, Peter M.

In: Journal of the American College of Cardiology, Vol. 70, No. 16, 17.10.2017, p. 1949-1961.

Research output: Contribution to journalArticleResearchpeer-review

TY - JOUR

T1 - Catheter Ablation Versus Medical Rate Control in Atrial Fibrillation and Systolic Dysfunction

T2 - The CAMERA-MRI Study

AU - Prabhu, Sandeep

AU - Taylor, Andrew J.

AU - Costello, Ben T.

AU - Kaye, David M.

AU - McLellan, Alex J.A.

AU - Voskoboinik, Aleksandr

AU - Sugumar, Hariharan

AU - Lockwood, Siobhan M.

AU - Stokes, Michael B.

AU - Pathik, Bhupesh

AU - Nalliah, Chrishan J.

AU - Wong, Geoff R.

AU - Azzopardi, Sonia M.

AU - Gutman, Sarah J.

AU - Lee, Geoffrey

AU - Layland, Jamie

AU - Mariani, Justin A.

AU - Ling, Liang han

AU - Kalman, Jonathan M.

AU - Kistler, Peter M.

PY - 2017/10/17

Y1 - 2017/10/17

N2 - Background Atrial fibrillation (AF) and left ventricular systolic dysfunction (LVSD) frequently co-exist despite adequate rate control. Existing randomized studies of AF and LVSD of varying etiologies have reported modest benefits with a rhythm control strategy. Objectives The goal of this study was to determine whether catheter ablation (CA) for AF could improve LVSD compared with medical rate control (MRC) where the etiology of the LVSD was unexplained, apart from the presence of AF. Methods This multicenter, randomized clinical trial enrolled patients with persistent AF and idiopathic cardiomyopathy (left ventricular ejection fraction [LVEF] ≤45%). After optimization of rate control, patients underwent cardiac magnetic resonance (CMR) to assess LVEF and late gadolinium enhancement, indicative of ventricular fibrosis, before randomization to either CA or ongoing MRC. CA included pulmonary vein isolation and posterior wall isolation. AF burden post-CA was assessed by using an implanted loop recorder, and adequacy of MRC was assessed by using serial Holter monitoring. The primary endpoint was change in LVEF on repeat CMR at 6 months. Results A total of 301 patients were screened; 68 patients were enrolled between November 2013 and October 2016 and randomized with 33 in each arm (accounting for 2 dropouts). The average AF burden post-CA was 1.6 ± 5.0% at 6 months. In the intention-to-treat analysis, absolute LVEF improved by 18 ± 13% in the CA group compared with 4.4 ± 13% in the MRC group (p < 0.0001) and normalized (LVEF ≥50%) in 58% versus 9% (p = 0.0002). In those undergoing CA, the absence of late gadolinium enhancement predicted greater improvements in absolute LVEF (10.7%; p = 0.0069) and normalization at 6 months (73% vs. 29%; p = 0.0093). Conclusions AF is an underappreciated reversible cause of LVSD in this population despite adequate rate control. The restoration of sinus rhythm with CA results in significant improvements in ventricular function, particularly in the absence of ventricular fibrosis on CMR. This outcome challenges the current treatment paradigm that rate control is the appropriate strategy in patients with AF and LVSD. (Catheter Ablation Versus Medical Rate Control in Atrial Fibrillation and Systolic Dysfunction [CAMERA-MRI]; ACTRN12613000880741)

AB - Background Atrial fibrillation (AF) and left ventricular systolic dysfunction (LVSD) frequently co-exist despite adequate rate control. Existing randomized studies of AF and LVSD of varying etiologies have reported modest benefits with a rhythm control strategy. Objectives The goal of this study was to determine whether catheter ablation (CA) for AF could improve LVSD compared with medical rate control (MRC) where the etiology of the LVSD was unexplained, apart from the presence of AF. Methods This multicenter, randomized clinical trial enrolled patients with persistent AF and idiopathic cardiomyopathy (left ventricular ejection fraction [LVEF] ≤45%). After optimization of rate control, patients underwent cardiac magnetic resonance (CMR) to assess LVEF and late gadolinium enhancement, indicative of ventricular fibrosis, before randomization to either CA or ongoing MRC. CA included pulmonary vein isolation and posterior wall isolation. AF burden post-CA was assessed by using an implanted loop recorder, and adequacy of MRC was assessed by using serial Holter monitoring. The primary endpoint was change in LVEF on repeat CMR at 6 months. Results A total of 301 patients were screened; 68 patients were enrolled between November 2013 and October 2016 and randomized with 33 in each arm (accounting for 2 dropouts). The average AF burden post-CA was 1.6 ± 5.0% at 6 months. In the intention-to-treat analysis, absolute LVEF improved by 18 ± 13% in the CA group compared with 4.4 ± 13% in the MRC group (p < 0.0001) and normalized (LVEF ≥50%) in 58% versus 9% (p = 0.0002). In those undergoing CA, the absence of late gadolinium enhancement predicted greater improvements in absolute LVEF (10.7%; p = 0.0069) and normalization at 6 months (73% vs. 29%; p = 0.0093). Conclusions AF is an underappreciated reversible cause of LVSD in this population despite adequate rate control. The restoration of sinus rhythm with CA results in significant improvements in ventricular function, particularly in the absence of ventricular fibrosis on CMR. This outcome challenges the current treatment paradigm that rate control is the appropriate strategy in patients with AF and LVSD. (Catheter Ablation Versus Medical Rate Control in Atrial Fibrillation and Systolic Dysfunction [CAMERA-MRI]; ACTRN12613000880741)

KW - catheter ablation

KW - idiopathic cardiomyopathy

KW - late gadolinium enhancement

KW - medical rate control

KW - persistent AF

UR - http://www.scopus.com/inward/record.url?scp=85031747699&partnerID=8YFLogxK

U2 - 10.1016/j.jacc.2017.08.041

DO - 10.1016/j.jacc.2017.08.041

M3 - Article

VL - 70

SP - 1949

EP - 1961

JO - Journal of the American College of Cardiology

JF - Journal of the American College of Cardiology

SN - 0735-1097

IS - 16

ER -