title: Long-Term Clinical Results of 2 Different Ablation Strategies in Patients With Paroxysmal and Persistent Atrial Fibrillation Evaluation of linear lesions in the left and right atrium in ablation of long-standing atrial fibrillation. Randomized study comparing duty-cycled bipolar and unipolar radiofrequency with point-by-point ablation in pulmonary vein isolation. Propafenone added to ibutilide increases conversion rates of persistent atrial fibrillation Maintenance of sinus rhythm with metoprolol CR initiated before cardioversion and repeated cardioversion of atrial fibrillation: a randomized double-blind placebo-controlled study. Does intensity of rate-control influence outcome in atrial fibrillation? An analysis of pooled data from the RACE and AFFIRM studies. Atrial Fibrillation Catheter Ablation Versus Surgical Ablation Treatment (FAST): A 2-Center Randomized Clinical Trial Monophasic versus biphasic waveform shocks for atrial fibrillation cardioversion in patients with concomitant amiodarone therapy. Substrate modification combined with pulmonary vein isolation improves outcome of catheter ablation in patients with persistent atrial fibrillation: a prospective randomized comparison. Changes in Atrial Fibrillation Cycle Length and Inducibility During Catheter Ablation and Their Relation to Outcome Randomized Evaluation of Right Atrial Ablation After Left Atrial Ablation of Complex Fractionated Atrial Electrograms for Long-Lasting Persistent Atrial Fibrillation Randomized Study Comparing Combined Pulmonary Vein–Left Atrial Junction Disconnection and Cavotricuspid Isthmus Ablation Versus Pulmonary Vein–Left Atrial Junction Disconnection Alone in Patients Presenting With Typical Atrial Flutter and Atrial Fibrillation Mitral valve surgery plus concomitant atrial fibrillation ablation is superior to mitral valve surgery alone with an intensive rhythm control strategy. Efficacy of three different ablative procedures to treat atrial fibrillation in patients with valvular heart disease: a randomised trial. Amiodarone versus diltiazem for rate control in critically ill patients with atrial tachyarrhythmias Pulmonary venous isolation versus additional substrate modification as treatment for paroxysmal atrial fibrillation Comparison of rate and rhythm control in hypertension patients with atrial fibrillation. Carvedilol alone or in combination with digoxin for the management of atrial fibrillation in patients with heart failure? Techniques, evaluation, and consequences of linear block at the left atrial roof in paroxysmal atrial fibrillation: a prospective randomized study. Comparison of monophasic and biphasic shocks for transthoracic cardioversion of atrial fibrillation Small or Large Isolation Areas Around the Pulmonary Veins for the Treatment of Atrial Fibrillation?: Results From a Prospective Randomized Study Quality of life and functional capacity in patients with atrial fibrillation and congestive heart failure. Comparison of four single-drug regimens on ventricular rate and arrhythmia-related symptoms in patients with permanent atrial fibrillation. A randomized double-blind study of epicardial left atrial cryoablation for permanent atrial fibrillation in patients undergoing mitral valve surgery: the SWEDish Multicentre Atrial Fibrillation study (SWEDMAF). External cardioversion of atrial fibrillation: comparison of biphasic vs monophasic waveform shocks. Prospective randomized comparison of left atrial and biatrial radiofrequency ablation in the treatment of atrial fibrillation. Cryoballoon ablation of pulmonary veins for paroxysmal atrial fibrillation: first results of the North American Arctic Front (STOP AF) pivotal trial. Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of symptomatic atrial fibrillation: a randomized trial. Control of Heart Rate Versus Rhythm in Rheumatic Atrial Fibrillation: A Randomized Study Impact of systematic isolation of superior vena cava in addition to pulmonary vein antrum isolation on the outcome of paroxysmal, persistent, and permanent atrial fibrillation ablation: results from a randomized study. Randomized comparison of encircling and nonencircling left atrial ablation for chronic atrial fibrillation. Ablation for longstanding permanent atrial fibrillation: results from a randomized study comparing three different strategies. Long-term maintenance of normal sinus rhythm in patients with current symptomatic atrial fibrillation: amiodarone vs propafenone, both in low doses. Low dose amiodarone and sotalol in the treatment of recurrent, symptomatic atrial fibrillation: a comparative, placebo controlled study. Efficacy and impact of monophasic versus biphasic countershocks for transthoracic cardioversion of persistent atrial fibrillation. Radiofrequency ablation for persistent atrial fibrillation in patients with advanced heart failure and severe left ventricular systolic dysfunction: a randomised controlled trial Pulmonary vein isolation and linear lesions in atrial fibrillation ablation Catheter Ablation Versus Antiarrhythmic Drugs for Atrial Fibrillation: The A4 Study Sotalol versus propafenone for long-term maintenance of normal sinus rhythm in patients with recurrent symptomatic atrial fibrillation. Is circumferential pulmonary vein isolation preferable to stepwise segmental pulmonary vein isolation for patients with paroxysmal atrial fibrillation? Effectiveness of the Maze Procedure Using Cooled-Tip Radiofrequency Ablation in Patients With Permanent Atrial Fibrillation and Rheumatic Mitral Valve Disease A Randomized Controlled Trial of the Efficacy and Safety of Electroanatomic Circumferential Pulmonary Vein Ablation Supplemented by Ablation of Complex Fractionated Atrial Electrograms Versus Potential-Guided Pulmonary Vein Antrum Isolation Guided by Intracardiac Ultrasound Microwave Ablation in Mitral Valve Surgery for Atrial Fibrillation (MAMA). Single procedure efficacy of isolating all versus arrhythmogenic pulmonary veins on long-term control of atrial fibrillation: a prospective randomized study. Maintenance of sinus rhythm after electrical cardioversion of persistent atrial fibrillation; sotalol vs bisoprolol. A trial of self-adhesive patch electrodes and hand-held paddle electrodes for external cardioversion of atrial fibrillation (MOBIPAPA). Verapamil versus digoxin and acute versus routine serial cardioversion for the improvement of rhythm control for persistent atrial fibrillation. Acute beta-adrenoceptor blockade improves efficacy of ibutilide in conversion of atrial fibrillation with a rapid ventricular rate. A randomized controlled trial of efficacy and ST change following use of the Welch-Allyn MRL PIC biphasic waveform versus damped sine monophasic waveform for external DC cardioversion. Anterior-posterior versus anterior-lateral electrode position for biphasic cardioversion of atrial fibrillation. The Australian Intervention Randomized Control of Rate in Atrial Fibrillation Trial (AIRCRAFT). Conversion efficacy of intravenous ibutilide compared with intravenous amiodarone in patients with recent-onset atrial fibrillation and atrial flutter. Sinus rhythm maintenance following DC cardioversion of atrial fibrillation is not improved by temporary precardioversion treatment with oral verapamil Comparison of surgical cut and sew versus radiofrequency pulmonary veins isolation for chronic permanent atrial fibrillation: a randomized study. Sotalol vs metoprolol for ventricular rate control in patients with chronic atrial fibrillation who have undergone digitalization: a single-blinded crossover study. Catheter ablation vs. antiarrhythmic drug treatment of persistent atrial fibrillation: a multicentre, randomized, controlled trial (SARA study) Circumferential Pulmonary Vein Ablation With Additional Linear Ablation Results in an Increased Incidence of Left Atrial Flutter Compared With Segmental Pulmonary Vein Isolation as an Initial Approach to Ablation of Paroxysmal Atrial Fibrillation Circumferential pulmonary-vein ablation for chronic atrial fibrillation. Success of serial external electrical cardioversion of persistent atrial fibrillation in maintaining sinus rhythm; a randomized study. Substrate and Trigger Ablation for Reduction of Atrial Fibrillation (STAR AF): a randomized, multicentre, international trial† Surgical treatment of permanent atrial fibrillation using microwave energy ablation: a prospective randomized clinical trial. Comparison of cardiac surgery with left atrial surgical ablation vs. cardiac surgery without atrial ablation in patients with coronary and/or valvular heart disease plus atrial fibrillation: final results of the PRAGUE-12 randomized multicentre study† Freedom From Atrial Tachyarrhythmias After Catheter Ablation of Atrial Fibrillation: A Randomized Comparison Between 2 Current Ablation Strategies Efficacy of catheter ablation and surgical CryoMaze procedure in patients with long-lasting persistent atrial fibrillation and rheumatic heart disease: a randomized trial. Amiodarone, sotalol, or propafenone in atrial fibrillation: which is preferred to maintain normal sinus rhythm? A randomized assessment of the incremental role of ablation of complex fractionated atrial electrograms after antral pulmonary vein isolation for long-lasting persistent atrial fibrillation. Signal-averaged P wave reflects change in atrial electrophysiological substrate afforded by verapamil following cardioversion from atrial fibrillation. Left mitral isthmus ablation associated with PV Isolation: long-term results of a prospective randomized study. Ventricular pacing vs dual chamber pacing in patients with persistent atrial fibrillation after atrioventricular node ablation: open randomized study. Is pretreatment with ibutilide useful for atrial fibrillation cardioversion when combined with biphasic shock? VERDICT: the Verapamil versus Digoxin Cardioversion Trial: A randomized study on the role of calcium lowering for maintenance of sinus rhythm after cardioversion of persistent atrial fibrillation. Intravenous diltiazem is superior to intravenous amiodarone or digoxin for achieving ventricular rate control in patients with acute uncomplicated atrial fibrillation* Pulmonary vein isolation using segmental versus electroanatomical circumferential ablation for paroxysmal atrial fibrillation An evaluation of the strategy of maintenance of sinus rhythm by antiarrhythmic drug therapy after ablation and pacing therapy in patients with paroxysmal atrial fibrillation. Catheter ablation treatment in patients with drug-refractory atrial fibrillation: a prospective, multi-centre, randomized, controlled study (Catheter Ablation For The Cure Of Atrial Fibrillation Study). Randomized Ablation Strategies for the Treatment of Persistent Atrial Fibrillation: RASTA Study Effects of Amiodarone and Diltiazem on Persistent Atrial Fibrillation Conversion and Recurrence Rates: A Randomized Controlled Study Comparison of rate and rhythm control in patients with atrial fibrillation and nonischemic heart failure. Randomized comparison between pulmonary vein antral isolation versus complex fractionated electrogram ablation for paroxysmal atrial fibrillation. Comparison of pharmacological and electrical cardioversion in permanent atrial fibrillation after prosthetic cardiac valve replacement: A prospective randomized trial Biphasic versus monophasic shock waveform for conversion of atrial fibrillation: the results of an international randomized, double-blind multicenter trial. Conversion of Atrial Fibrillation to Sinus Rhythm During Treatment With Intravenous Esmolol or Diltiazem: A Prospective, Randomized Comparison Left ventricular-based cardiac stimulation post AV nodal ablation evaluation (the PAVE study). Effect of shock polarity on the efficacy of transthoracic atrial defibrillation. Left atrial radiofrequency ablation during mitral valve surgery for continuous atrial fibrillation: a randomized controlled trial. Comparison of effectiveness of carvedilol versus bisoprolol for maintenance of sinus rhythm after cardioversion of persistent atrial fibrillation. A short-term, randomized, double-blind, parallel-group study to evaluate the efficacy and safety of dronedarone versus amiodarone in patients with persistent atrial fibrillation: the DIONYSOS study. Randomized comparison of anterolateral versus anteroposterior electrode position for biphasic external cardioversion of atrial fibrillation. Catheter ablation of atrial fibrillation in patients with diabetes mellitus type 2: results from a randomized study comparing pulmonary vein isolation versus antiarrhythmic drug therapy. Efficacy of an additional MAZE procedure using cooled-tip radiofrequency ablation in patients with chronic atrial fibrillation and mitral valve disease. A randomized, prospective trial. A randomised, controlled study of rate versus rhythm control in patients with chronic atrial fibrillation and heart failure: (CAFÉ-II Study) DC cardioversion of persistent atrial fibrillation: a comparison of two protocols. Importance of rate control or rate regulation for improving exercise capacity and quality of life in patients with permanent atrial fibrillation and normal left ventricular function: a randomised controlled study Clinical assessment of clonidine in the treatment of new-onset rapid atrial fibrillation: a prospective, randomized clinical trial. Effects of a high dose intravenous bolus amiodarone in patients with atrial fibrillation and a rapid ventricular rate. A prospective, randomized controlled trial comparing the efficacy and safety of sotalol, amiodarone, and digoxin for the reversion of new-onset atrial fibrillation. Randomised comparison of antero-lateral versus antero-posterior paddle positions for DC cardioversion of persistent atrial fibrillation. Acute ventricular rate control in atrial fibrillation: IV combination of diltiazem and digoxin vs. IV diltiazem alone. Biphasic energy selection for transthoracic cardioversion of atrial fibrillation. The BEST AF Trial Anterior-posterior versus anterior-lateral electrode positions for external cardioversion of atrial fibrillation: a randomised trial Higher Energy Monophasic DC Cardioversion for Persistent Atrial Fibrillation: Is it Time to Start at 360 Joules? Left Atrial Posterior Wall Isolation Does Not Improve the Outcome of Circumferential Pulmonary Vein Ablation for Atrial Fibrillation: A Prospective Randomized Study Left atrial ablation versus biatrial ablation for persistent and permanent atrial fibrillation: a prospective and randomized study. A randomized trial of circumferential pulmonary vein ablation versus antiarrhythmic drug therapy in paroxysmal atrial fibrillation: the APAF Study. Quality of life and exercise performance in patients in sinus rhythm versus persistent atrial fibrillation: a Veterans Affairs Cooperative Studies Program Substudy. Role of residual potentials inside circumferential pulmonary veins ablation lines in the recurrence of paroxysmal atrial fibrillation. Rate control and quality of life in patients with permanent atrial fibrillation: the Quality of Life and Atrial Fibrillation (QOLAF) Study. Impact of biphasic electrical cardioversion of atrial fibrillation on early recurrent atrial fibrillation and shock efficacy. Biphasic versus monophasic cardioversion in shock-resistant atrial fibrillation:. Cardiac rate normalization in chronic atrial fibrillation: comparison of long-term efficacy of treatment with amiodarone versus AV node ablation and permanent His-bundle pacing. Comparison of the effectiveness of intravenous diltiazem and metoprolol in the management of rapid ventricular rate in atrial fibrillation Amiodarone to prevent recurrence of atrial fibrillation. Canadian Trial of Atrial Fibrillation Investigators. Does electrogram guided substrate ablation add to the success of pulmonary vein isolation in patients with paroxysmal atrial fibrillation? A prospective, randomized study. Atrial Fibrillation Ablation Strategies for Paroxysmal Patients: Randomized Comparison Between Different Techniques Does intensity of rate control influence outcome in persistent atrial fibrillation? Data of the RACE study. The impairment of health-related quality of life in patients with intermittent atrial fibrillation: implications for the assessment of investigational therapy. Prophylactic cavotricuspid isthmus block during atrial fibrillation ablation in patients without atrial flutter: a randomised controlled trial Rate control vs rhythm control in patients with nonvalvular persistent atrial fibrillation: the results of the Polish How to Treat Chronic Atrial Fibrillation (HOT CAFE) Study. Comparison of carvedilol and metoprolol on clinical outcomes in patients with chronic heart failure in the Carvedilol Or Metoprolol European Trial (COMET): randomised controlled trial Randomized trial of rate-control versus rhythm-control in persistent atrial fibrillation: the Strategies of Treatment of Atrial Fibrillation (STAF) study. Combined radiofrequency modified maze and mitral valve procedure through a port access approach: early and mid-term results. Antiarrhythmic drug therapy after radiofrequency catheter ablation in patients with atrial fibrillation. A randomized, prospective comparison of anterior and posterior approaches to atrioventricular junction modification of medically refractory atrial fibrillation. Ablation of atypical atrial flutter guided by the use of concealed entrainment in patients without prior cardiac surgery. Maintenance of sinus rhythm in patients with atrial fibrillation: an AFFIRM substudy of the first antiarrhythmic drug. Efficacy of transthoracic cardioversion of atrial fibrillation using a biphasic, truncated exponential shock waveform at variable initial shock energies. Ablation of superior pulmonary veins compared to ablation of all four pulmonary veins:. Oral amiodarone increases the efficacy of direct-current cardioversion in restoration of sinus rhythm in patients with chronic atrial fibrillation. A randomized study of combining maze surgery for atrial fibrillation with mitral valve surgery. Catheter ablation for paroxysmal atrial fibrillation: a randomized comparison between multielectrode catheter and point-by-point ablation. A randomized trial to assess catheter ablation versus rate control in the management of persistent atrial fibrillation in heart failure. Comparison of cool tip versus 8-mm tip catheter in achieving electrical isolation of pulmonary veins for long-term control of atrial fibrillation: a prospective randomized pilot study. Initial energy for elective external cardioversion of persistent atrial fibrillation. Functional status in rate- versus rhythm-control strategies for atrial fibrillation: results of the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) Functional Status Substudy. Maintenance of sinus rhythm and survival in patients with heart failure and atrial fibrillation. Pharmacological conversion of recent atrial fibrillation: a randomized, placebo-controlled study of three antiarrhythmic drugs. Prospective, randomized comparison of two biphasic waveforms for the efficacy and safety of transthoracic biphasic cardioversion of atrial fibrillation. Pulmonary vein isolation combined with superior vena cava isolation for atrial fibrillation ablation: a prospective randomized study. A randomized trial of prophylactic antiarrhythmic agents (amiodarone and sotalol) in patients with atrial fibrillation for whom direct current cardioversion is planned. Effects of diltiazem pretreatment on direct-current cardioversion in patients with persistent atrial fibrillation: a single-blind, randomized, controlled study. Comparative effects of carvedilol and amiodarone on conversion and recurrence rates of persistent atrial fibrillation. Recurrence of pulmonary vein conduction and atrial fibrillation after pulmonary vein isolation for atrial fibrillation: a randomized trial of the ostial versus the extraostial ablation strategy. A randomized clinical trial of the efficacy of radiofrequency catheter ablation and amiodarone in the treatment of symptomatic atrial fibrillation. Randomized study of surgery for patients with permanent atrial fibrillation as a result of mitral valve disease. Long-term efficacy and safety of propafenone and sotalol for the maintenance of sinus rhythm after conversion of recurrent symptomatic atrial fibrillation. Left atrial radiofrequency ablation during mitral valve surgery: a prospective randomized multicentre study (SAFIR). Rapid loading of sotalol or amiodarone for management of recent onset symptomatic atrial fibrillation: a randomized, digoxin-controlled trial. Comparison of antiarrhythmic drug therapy and radiofrequency catheter ablation in patients with paroxysmal atrial fibrillation: a randomized controlled trial. Calcium channel blockers improve exercise capacity and reduce N-terminal Pro-B-type natriuretic peptide levels compared with beta-blockers in patients with permanent atrial fibrillation. A comparison of rectilinear and truncated exponential biphasic waveforms in elective cardioversion of atrial fibrillation: a prospective randomized controlled trial.
abstract: Background — Data regarding the long-term efficacy of atrial fibrillation ( AF ) ablation are still lacking . Methods and Results —Two hundred four consecutive patients symptomatic for paroxysmal or persistent/permanent AF were r and omly assigned to 2 different ablation schemes : pulmonary vein isolation ( PVI ) and PVI plus left linear lesions ( LL ) . Primary end point was to assess the maintenance of sinus rhythm ( SR ) after procedures 1 and 2 in the absence of antiarrhythmic drugs in a long-term follow-up of at least 3 years . Paroxysmal AF — With a single procedure at 12-month follow-up , 46 % of patients treated with PVI maintained SR , whereas at 3-year follow-up , 29 % were in SR ; using the “ PVI plus LL ” at the 12-month follow-up , 57 % of patients were in SR , whereas at the 3-year follow-up , 53 % remained in SR . After a second procedure , the long-term overall success rate without antiarrhythmic drugs was 62 % with PVI and 85 % with PVI plus LL . Persistent/Permanent AF — With a single procedure at the 12-month follow-up , 27 % of patients treated with PVI were in SR , whereas at the 3-year follow-up , 19 % maintained SR ; using the PVI plus LL with a single procedure at the 12-month follow-up 45 % of patients were in SR , whereas at the 3-year follow-up , 41 % remained in SR . After a second procedure , the long-term overall success rate without antiarrhythmic drugs was 39 % with PVI and 75 % with PVI plus LL . Conclusions —A long-term follow-up of AF ablation shows that short-term results can not be considered permanent because AF recurrences are still present after the first year especially in patients who have had “ PVI ” strategy .  PVI isolation plus LL is superior to the PVI strategy in maintaining SR without antiarrhythmic drugs after procedures 1 and 2 both in paroxysmal and persistent AF BACKGROUND This r and omized prospect i ve study compared three ablation strategies in patients with long-st and ing persistent atrial fibrillation ( LPeAF ) . It also explored the best procedural endpoint from among the following : circumferential pulmonary vein isolation ( PVI ) + left atrial ( LA ) linear lesions ( roofline , mitral isthmus ) + complex fractionated atrial electrogram ( CFAE ) ablation , PVI + LA linear lesions + cavotricuspid isthmus ( CTI ) ablation + CFAE ablation , and PVI + CFAE ablation . METHODS AND RESULTS A total of 210 patients with LPeAF referred for catheter ablation were enrolled and r and omized into three ablation groups . The patients in group A ( n = 70 ) underwent PVI followed by LA linear and CFAE ablation ; in 93 % of patients the primary endpoint was achieved ( five patients with incomplete linear lesions ) . Of the 70 patients in group B who were subjected to PVI followed by LA linear , CFAE , and CTI ablations , in 94 % of patients the primary endpoint was achieved ( four patients with incomplete linear lesions ) . All patients in group C ( n = 70 ) successfully underwent PVI and CFAE ablation . Direct current cardioversion was performed upon PVI , CFAE elimination , and completion of linear lesions . Patients were followed-up for atrial tachyarrhythmia recurrence for at least 24 months . After a single ablation procedure , group C ( 36 % ) exhibited the lowest success compared with group A ( 54 % ) and group B ( 51 % ) ( P = 0.06 ) . At the mean follow-up of 32 ± 9 months after the final ablation procedure , 53 patients ( 76 % ) in group A , 53 ( 76 % ) in group B , and 41 ( 59 % ) in group C were in sinus rhythm without antiarrhythmic drugs ( P = 0.03 ) . CONCLUSIONS In LPeAF , linear lesions in the LA help improve outcome of ablation , additional CTI ablation does not BACKGROUND Pulmonary vein ( PV ) electrical isolation is a therapeutic option in atrial fibrillation ( AF ) . New technologies may reduce the complexity of the procedure . OBJECTIVE The aim of the present study was to compare immediate results and short-term efficacy of a new circular ablation catheter ( PVAC ) with a conventional point-by-point ablation . METHODS The prospect i ve study enrolled 80 consecutive patients with paroxysmal AF or persistent AF , refractory to antiarrhythmic drugs , who were r and omized to radiofrequency ablation using duty-cycled bipolar and unipolar radiofrequency by a decapolar circular catheter ( PVAC group ) or to point-by-point ablation supported by a 3-dimensional mapping system ( 3D group ) . RESULTS Forty patients per group were included . Mean age was 58 ± 10 years , 64 % were male ; 55 % had paroxysmal AF , 45 % had persistent AF . There were no significant differences between groups . Complete electrical isolation was reached in all but 1 PV , which was not isolated in the PVAC group because of phrenic nerve capture . Procedure and fluoroscopy times were lower in the PVAC group : 171 ± 40 minutes vs. 224 ± 27 minutes , P < .001 ; 26 ± 8 minutes vs. 35 ± 9 minutes , P < .001 ; respectively . There were no major complications . During a mean follow-up of 254 ± 99 days , 72 % in the PVAC group and 68 % in the 3D group were free of AF recurrences irrespective of the initial AF type ( P = NS ) . CONCLUSION PVAC represents a safe alternative for PV isolation . It reduces both procedure and fluoroscopy time . The short- and middle-term efficacy is comparable to a conventional point-by-point antral ablation technique Objective : To assess the effectiveness and safety of pharmacological conversion of persistent atrial fibrillation ( AF ) with a combined propafenone plus ibutilide regimen . Methods and results : 100 consecutive patients ( 66 men , mean ( SD ) age 65 ( 10 ) years ) with persistent AF ( mean ( SD ) duration 99 ( 92 ) days ) admitted for elective pharmacological cardioversion were r and omly assigned to treatment with either intravenous ibutilide ( 1 mg plus an additional 1 mg , if required ; n = 51 ) or oral propafenone ( 600 mg ) plus intravenous ibutilide at the same dose ( n = 49 ) . Success rates were 41.1 % ( 21 of 51 patients ) for ibutilide alone and 71.4 % ( 35 of 49 patients ) for propafenone plus ibutilide ( p = 0.0044 ) . However , cardioversion occurred earlier in the ibutilide alone group ( 55 ( 20 ) minutes ) compared with the combination group ( 81 ( 32 ) minutes , p = 0.0019 ) . A comparable increase in the QTc interval was observed in both groups but one case of sustained torsade de pointes , requiring electrical cardioversion , was observed in the propafenone plus ibutilide group . No other complications were noted during the hospitalisation period . Conclusion : Concurrent administration of propafenone plus ibutilide for pharmacological cardioversion of persistent AF is safe and more effective than ibutilide alone AIMS To assess the effect of metoprolol in combination with repeated cardioversion on maintenance of sinus rhythm ( SR ) . METHODS AND RESULTS Consecutive out patients with persistent atrial fibrillation ( AF ) were r and omized to treatment with metoprolol CR or placebo in a double-blind fashion . Study treatment was started at least one week before direct current ( DC ) cardioversion . Patients were followed once a week during the first 6 weeks after cardioversion . In case of relapse during this period , a second cardioversion was performed . Total treatment time was 6 months . A total of 168 patients were r and omized to metoprolol  ( n = 83 ) or placebo ( n = 85 ) . The dose of study treatment at cardioversion was 169 + /- 47 mg in the metoprolol group and 180 + /- 40 mg in the placebo group ( P = 0.12 ) . In an intention-to-treat analysis , 46 patients ( 55 % ) in the metoprolol group and 34 patients ( 40 % ) in the placebo group ( P = 0.04 ) had SR 1 week after cardioversion , and 38 patients ( 46 % ) in the metoprolol group compared with 22 patients ( 26 % ) in the placebo group had SR after 6 months ( P < 0.01 ) . CONCLUSION A treatment strategy of metoprolol CR started before cardioversion in combination with prompt second cardioversion in case of early relapse ( 1 - 6 weeks ) significantly increases the proportion of patients in SR during six months of follow-up AIMS The AFFIRM and RACE studies showed that rate control is an acceptable treatment strategy for  atrial fibrillation ( AF ) .  We examined whether strict rate control offers benefit over more lenient rate control . METHODS AND RESULTS We compared the outcome of patients enrolled in the rate-control arms of AFFIRM and RACE , using data from patients who met a composite of overlapping inclusion and exclusion criteria . We evaluated 1091 patients , 874 from AFFIRM and 217 from RACE . In AFFIRM , the rate-control strategy aim ed for a resting heart rate < or = 80 bpm and heart rate during daily activity of < or = 110 bpm . In RACE , a more lenient approach was taken : resting heart rate < 100 bpm . Primary endpoint was a composite of mortality , cardiovascular hospitalization , and myocardial infa rct ion . Mean heart rate across all follow-up visits for patients in AF was lower in AFFIRM ( 76.1 vs. 83.4 bpm ) . Event-free survival for the occurrence of the primary endpoint did not differ ( 64 % in AFFIRM vs. 66 % in RACE ) . Patients with mean heart rates during AF within the AFFIRM ( < or = 80 ) or RACE ( < 100 ) criteria had a better outcome than patients with heart rates > or = 100 ( hazard ratios 0.69 and 0.58 , respectively , for < or = 80 and < 100 compared with > or = 100 bpm ) . CONCLUSION Stringency of the approach to rate control , based on the comparison of the AFFIRM and RACE studies , was not associated with an important difference in clinical events Background — Catheter ablation ( CA ) and minimally invasive surgical ablation ( SA ) have become accepted therapy for antiarrhythmic drug – refractory atrial fibrillation . This study describes the first r and omized clinical trial comparing their efficacy and safety during a 12-month follow-up . Methods and Results — One hundred twenty-four patients with antiarrhythmic drug – refractory atrial fibrillation with left atrial dilatation and hypertension ( 42 patients , 33 % ) or failed prior CA ( 82 patients , 67 % ) were r and omized to CA ( 63 patients ) or SA ( 61 patients ) . CA consisted of linear antral pulmonary vein isolation and optional additional lines . SA consisted of bipolar radiofrequency isolation of the bilateral pulmonary vein , ganglionated plexi ablation , and left atrial appendage excision with optional additional lines . Follow-up at 6 and 12 months was performed by ECG and 7-day Holter recording . The primary end point , freedom from left atrial arrhythmia > 30 seconds without antiarrhythmic drugs after 12 months , was 36.5 % for CA and 65.6 % for SA ( P=0.0022 ) . There was no difference in effect for subgroups , which was consistent at both sites . The primary safety end point of significant adverse events during the 12-month follow-up was significantly higher for SA than for CA ( n=21 [ 34.4 % ] versus n=10 [ 15.9 % ] ; P=0.027 ) , driven mainly by procedural complications such as pneumothorax , major bleeding , and the need for pacemaker . In the CA group , 1 patient died at 1 month of subarachnoid hemorrhage . Conclusion — In atrial fibrillation patients with dilated left atrium and hypertension or failed prior atrial fibrillation CA , SA is superior to CA in achieving freedom from left atrial arrhythmias after 12 months of follow-up , although the procedural adverse event rate is significantly higher for SA than for CA . Clinical Trial Registration — URL : http:// clinical trials.gov . Unique identifier : NCT00662701 AIMS With transthoracic cardioversion of atrial fibrillation ( AF ) , biphasic are more effective than monophasic waveforms . We sought to determine the ideal energy levels for biphasic waveforms . Methods We compared biphasic truncated exponential waveforms with monophasic damped sine waveform defibrillators , in a prospect i ve , single-centre , r and omized ( 1:1 ratio ) study . The study included 154 patients receiving concomitant amiodarone ;  77 received serial biphasic ( 50 , 100 , 150 , up to 175 J ) and 77 monophasic shocks ( 100 , 200 , 300 , up to 360 J ) , as necessary . Results First-shock efficacy was similar in the two groups ( 57 vs. 55 % , P = 0.871 , respectively ) , as were serial-shocks ( 90 vs. 92 % , P = 0.780 ) . Both groups received equal numbers of shocks ( 1.8 + /- 1.1 vs. 1.7 + /- 1.0 , P = 0.921 ) . In both groups , serum creatine kinase levels showed a small but significant increase . The increase was , however , higher in the monophasic group . CONCLUSION In patients with concomitant amiodarone therapy , biphasic truncated exponential shocks , using half the energy , were as effective as monophasic damped sine shocks . The biphasic scheme was not more efficacious for cardioverting AF . In our population , a first shock of at least 100 J seemed advisable with either waveform . If necessary , escalating shocks must be performed , but ideal levels of increase per shock are still uncertain for biphasic waveforms AIMS To investigate the effectiveness of additional substrate modification ( SM ) by left atrial ( LA ) linear lesions as compared with pulmonary vein isolation ( PVI ) alone in patients with persistent atrial fibrillation ( AF ) in a prospect i ve r and omized study . Percutaneous PVI has evolved as an accepted treatment for paroxysmal AF but seemed to be less effective in patients with persistent AF . The benefit of PVI alone and additional linear lesions has not been vali date d in a r and omized study so far . METHODS AND RESULTS Sixty-two patients with persistent AF ( median duration 7 , range 1 - 18 months ) were r and omly assigned to either PVI alone ( n = 30 ) or additional SM ( n = 32 ) consisting of a roof line connecting both left superior and right superior PV and LA isthmus ablation between left inferior PV and mitral annulus . Procedures including SM were performed using a three-dimensional mapping system ( EnSite NavX , St Jude Medical , St Paul , MN , USA ) . Anti-arrhythmic drugs were discontinued within 8 weeks after ablation in both groups . Follow-up included daily trans-telephonic ECG transmitted irrespective of the patient 's symptoms . PVI was successful in 98 % of all targeted veins in both groups . Additional SM did not increase fluoroscopy time ( 72.1+/-18.7 vs. 72.9+/-17.3 min , P=0.92 ) because of the use of three-dimensional navigation in the PVI+SM group . AF recurrences within the first 4 weeks following ablation were more common after PVI alone ( 77 % ) than additional SM ( 44 % , P=0.002 ) . After a follow-up time of 487 ( 429 - 570 ) days , only 20 % of patients undergoing st and alone PVI  remained in sinus rhythm when compared with 69 % following PVI combined with SM ( P=0.0001 ) . Two patients assigned to PVI+SM experienced procedure-related complications ( cardiac tamponade and minor stroke ) which resolved without sequelae . CONCLUSION PVI alone is insufficient in the treatment of persistent AF . However , additional left linear lesions increase the success rate significantly . Early AF-relapses are associated with a negative outcome after PVI alone but not following additional SM Background —The modification of atrial fibrillation cycle length ( AFCL ) during  catheter ablation in humans has not been evaluated . Methods and Results —Seventy patients undergoing ablation of prolonged episodes of AF were r and omized to pulmonary vein ( PV ) isolation or additional ablation of the mitral isthmus .  Mean AFCL was determined at a distance from the ablated area ( coronary sinus ) at the following intervals : before ablation , after 2- and 4-PV isolations , and after linear ablation . Inducibility of sustained AF ( ≥10 minutes ) was determined before and after ablation . Spontaneous sustained AF ( 715±845 minutes ) was present in 30 patients and induced in 26 ( AFCL , 186±19 ms ) . PV isolation terminated AF in 75 % , with the number of PVs requiring isolation before termination increasing with AF duration ( P = 0.018 ) . PV isolation result ed in progressive or abrupt AFCL prolongation to various extents , depending on the PV : to 214±24 ms ( P < 0.0001 ) when AF terminated and to 194±19 ms ( P < 0.002 ) when AF persisted . The increase in AFCL ( 30±17 versus 14±11 ms ; P = 0.005 ) and the decrease in fragmentation ( 30.0±26.8 % to 10.3±14.5 % ; P < 0.0001 ) were significantly greater in patients with AF termination . Linear ablation prolonged AFCL , with a greater prolongation in patients with AF termination ( 44±13 versus 22±23 ms ; P = 0.08 ) . Sustained AF was noninducible in 57 % after PV isolation and in 77 % after linear ablation . At 7±3 months , 74 % with PV isolation and 83 % with linear ablation were arrhythmia free without antiarrhythmics , which was significantly associated with noninducibility ( P = 0.03 ) with a recurrence rate of 38 % and 13 % in patients with and without inducibility , respectively . Conclusions —AF ablation results in a decline in AF frequency , with a magnitude correlating with termination of AF and prevention of inducibility that is predictive of subsequent clinical outcome Background —With electrogram-guided radiofrequency ablation ( RFA ) of long-lasting persistent atrial fibrillation ( AF ) , the best results have been reported when complex fractionated electrograms ( CFAEs ) in both the left ( LA ) and right ( RA ) atria were targeted . However , many studies have reported excellent outcomes from RFA of long-lasting persistent AF with the use of other ablation strategies that were limited to the LA . The incremental value of RFA of RA CFAEs is yet to be defined . Methods and Results —In 85 patients with long-lasting persistent AF ( age=59±10 years ) , RFA was directed at CFAEs in the LA and coronary sinus until AF terminated ( 19 ) or all identified LA CFAEs were eliminated . Sixty-six patients who remained in AF were r and omly assigned to cardioversion and no further RFA ( n=33 ) or to RFA of RA CFAEs ( n=33 ) . RA sites consisted of the crista terminalis ( 69 % ) , septum ( 38 % ) , superior vena cava ( 28 % ) , coronary sinus ostium ( 22 % ) , and the base of the appendage ( 31 % ) . AF terminated in 1 ( 3 % ) of 33 patients during RA RFA . At 17±6 months after a single ablation procedure , 74 % of the patients in whom AF terminated during LA RFA were in sinus rhythm . Rates of freedom from AF were similar in the patients r and omized to no RFA in the RA ( 24 % ) and those r and omized to RFA of RA CFAEs ( 30 % , P=0.8 ) . The ablation procedure was repeated in 26 patients ( 31 % ) for AF ( n=22 ) or atrial flutter ( n=4 ) . At 16±7 months after the final procedure , 89 % of the patients in whom AF terminated during LA RFA were in sinus rhythm . Among the r and omized patients , the proportion of patients who remained in sinus rhythm was similar in patients who did not undergo RFA of RA CFAEs ( 52 % ) and those who did ( 58 % , P=0.6 ) . Conclusion —After RFA of CFAEs in the LA and coronary sinus , ablation of CFAEs in the RA provides little or no increment in efficacy among patients with long-lasting persistent AF Background —Atrial flutter ( AFL ) and atrial fibrillation ( AF ) frequently coexist in the same patient . Recently it has been demonstrated that the triggers for both AF and AFL may originate in the pulmonary veins ( PVs ) . We hypothesized that in patients with both AF and typical AFL , pulmonary vein – left atrial junction ( PV-LAJ ) disconnection may eliminate both arrhythmias . Methods and Results —Consecutive patients with documented symptomatic AF and typical AFL were r and omly assigned to have PV-LAJ disconnection combined with cavotricuspid isthmus ( CTI ) ablation ( group 1 , n=49 ) or PV-LAJ disconnection alone ( group 2 , n=59 ) . Within the first 8 weeks after ablation , 32 of the group 2 patients had typical AFL documented , whereas none was seen in group 1 . Twenty of these 32 converted to sinus rhythm after initiating antiarrhythmic drugs ( AADs ) . Twelve were cardioverted , and AADs were started . After 8 weeks , all AADS were stopped , and only 3 patients continued to have recurrent sustained typical AFL that was eliminated by CTI ablation . Beyond 8 weeks of follow-up , 7 patients in group 1 and 6 patients in group 2 ( 14 % and 11 % , respectively ) continued to have AF . Ten of these 13 patients underwent a repeat PV-LAJ disconnection procedure and were cured . The remaining 3 remained in normal sinus rhythm while taking AADs . Conclusions —In patients with both AFL and AF , PV-LAJ disconnection alone may be sufficient to control both arrhythmias . CTI block reduced early postablation recurrence of arrhythmias , which in the majority of patients reflects a short-term clinical problem OBJECTIVE Prospect i ve r and omised study comparing patients with atrial fibrillation ( AF ) of more than 6 months duration after mitral valve surgery plus biatrial modified radiofrequency Maze procedure using Medtronic Cardioblate System ( Cardioblate group , n=24 ) vs mitral valve surgery plus intensive rhythm control strategy ( control group , n=25 ) . METHODS Patients were blinded to r and omisation . Preoperatively , at discharge , and at 3-month and 1-year follow-up ,  echocardiography , quality of life assessment s and ECGs  were done . In both groups , sinus rhythm ( SR ) restoration was attempted by intra- and postoperative DC cardioversion and class III antiarrhythmic medication . All patients received warfarin . Amiodarone and warfarin was considered for discontinuation after 3 months in SR , 24-h Holter or event monitor excluding AF . RESULTS Both groups underwent mitral valve replacement or repair ( Cardioblate vs control : 16:8 vs 10:15 ) , had similar gender ( male : 33 % vs 56 % ) , age ( 66+/-8 years vs 68+/-9 years ) , additional aortic valve replacement ( 7 vs 6 patients ) , tricuspid annuloplasty ( 13 vs 13 patients ) , and CABG ( 10 vs 16 patients ) . There was 0 % operative mortality , 0 % postoperative cerebrovascular accidents , but 2 late deaths in the control group . At discharge , 3- and 12-month follow-up , more patients in the Cardioblate group returned to normal SR compared to control ( 29 % , 57 % and 75 % vs 20 % , 43 % and 39 % ; p=0.030 ) . Return of functional atrial contraction in patients in SR at 1 year was comparable between groups ( 63 % vs 89 % , NS ) , and more likely in non-rheumatic pathology and preoperative AF of shorter duration . The effectiveness of atrial contraction was 36+/-14 % vs 43+/-18 % of transmitral flow and there was no difference between groups .  Amiodarone treatment decreased more in Cardioblate group over time ( 92 % , 55 % and 29 % vs 52 % , 52 % and 21 % ; p=0.003 ) , whereas warfarin decrease was comparable ( 100 % , 100 % and 71 % vs 100 % , 95 % and 82 % ; NS ) . CONCLUSIONS Radiofrequency Maze ablation additional to mitral valve surgery result ed in a higher SR conversion rate ( 75 % ) , despite control group treatment with intensive rhythm control strategy having a higher SR conversion rate ( 39 % ) compared to literature ( approximately 25 % ) . Maze ablation result ed in normalisation of atrial function in 63 % of patients converted to SR OBJECTIVES Various modifications have been proposed to the original Cox 's Maze procedure due to concerns about the long bypass and cross clamp times . The efficacy of these procedures has been studied and reported . We conducted a r and omised prospect i ve study to compare three procedures , differing in extent , of ablation in patients in atrial fibrillation who were undergoing surgery for rheumatic valvular heart disease . These procedures utilised radiofrequency in the bipolar mode . The extent of ablation was ( 1 ) biatrial ( replication of the Cox Maze ) ( 2 ) left atrial portion of the Cox Maze and ( 3 ) pulmonary vein isolation along with a control group ( the No Maze group ) . Conversion rate to sinus rhythm was studied over a mid-term follow-up period . METHODS A total of 160 patients were studied with 40 patients in each group .  Antiarrhythmic drugs were not used in the three months preceding surgery and for seven days postoperatively . The patients underwent surgery for their valve disease along with the ablative procedure as per r and omisation using radiofrequency microbipolar coagulation and cryoablation . They were followed up and were evaluated for symptomatic improvement , rhythm with ECG documentation and 2D echocardiography . RESULTS Follow-up was available for 133 patients . Mid-term results showed that sinus rhythm was restored in 62.5 % patients of Biatrial Maze group and 57.5 % in the Left Atrial Maze . In the Pulmonary Vein Isolation Maze group , 67.5 % patients converted to NSR whereas in the No Maze group only 20 % patients were in sinus rhythm ( p value for all the groups was 0.001 when compared to the No Maze group ) . The incidence of other arrhythmias was not significant and there were no other major complications . All the patients in sinus rhythm at follow-up were in NYHA functional class I-II and showed good effort tolerance . CONCLUSIONS Results achieved with the three ablative procedures are comparable . Therefore lesser procedures viz . Left Atrial Maze and the Pulmonary Vein Isolation Maze procedures must be studied further with the additional use of antiarrhythmic drugs Objective To compare the rate-lowering effect of diltiazem and two amiodarone regimens in critically ill patients with recent-onset atrial tachyarrhythmias . Design Prospect i ve , r and omized , controlled study . Setting Medical cardiologic intensive care unit in a university hospital . Patients Sixty critically ill patients ( Acute Physiology and Chronic Health Evaluation [ APACHE ] III score 70 ± 30 , age 67 ± 10 yrs ) . Interventions Patients with atrial fibrillation ( n = 57 ) , atrial flutter ( n = 2 ) , or atrial tachycardia ( n = 1 , and a heart rate consistently > 120 beats/min over 30 mins were r and omly assigned to one of three intravenous treatment regimens . Group 1 received diltiazem in a 25-mg bolus followed by a continuous infusion of 20 mg/hr for 24 hrs , group 2 received amiodarone in a 300-mg bolus , and group 3 received amiodarone in a 300-mg bolus followed by 45 mg/hr for 24 hrs . Measurements and Main Results The primary study end point was a > 30 % rate reduction within 4 hrs . The secondary study end point was a heart rate < 120 beats/min ( a patient was considered to have uncontrolled tachycardia if heart rate was > 120 beats/min 4 hrs after study drug ) . The primary study end point was achieved in 14/20 ( 70 % ) , 11/20 ( 55 % ) , and 15/20 ( 75 % ) of patients in groups 1 , 2 , and 3 , respectively ( & khgr;2 = 1.95 , p = .38 ) . Uncontrolled tachycardia was more frequently observed in group 2 ( 0/20 , 9/29 [ 55 % ] , and 1/20 [ 5 % ] of patients in groups 1 , 2 , and 3 , respectively ; & khgr;2 = 17 , p = .00016 ) . In patients achieving tachycardia control , diltiazem showed a significantly better rate reduction ( p = .0001 group 1 vs. group 3 , p = .0001 over time;p = .0001 group 1 vs. group 2 , p = .001 over time ) when compared with the amiodarone  groups . Premature drug discontinuation due to hypotension was required significantly more often in group 1 ( 6/20 [ 30 % ] , 0/20 , and 1/20 [ 5 % ] for groups 1 , 2 , and 3 , respectively ; & khgr;2 = 10 , p = .01 ) . Conclusion Sufficient rate control can be achieved in critically ill patients with atrial tachyarrhythmias using either diltiazem or amiodarone . Although diltiazem allowed for significantly better 24-hr heart rate control , this effect was offset by a significantly higher incidence of hypotension requiring discontinuation of the drug . Amiodarone may be an alternative in patients with severe hemodynamic compromise Background Pulmonary vein isolation alone is ineffective in maintaining sinus rhythm in up to one third of patients with paroxysmal atrial fibrillation ( AF ) . We compared pulmonary vein antral isolation plus additional limited ablation along the inferoposterior left atrium and epicardially within the adjacent coronary sinus ( PVAI + CS ) to pulmonary vein antral isolation ( PVAI ) alone in patients with paroxysmal AF . Methods Forty-two consecutive patients with paroxysmal AF were prospect ively r and omized to PVAI vs. PVAI + CS . All patients were seen 3 , 6 , 12 , and 18 months after ablation and underwent 24-h ambulatory Holter monitoring . Results Following a single procedure , 17 out of 22 patients ( 77 % ) remained arrhythmia free off antiarrhythmic medication after PVAI at 18 months vs. 10 out of 20 ( 50 % ) after PVAI + CS ( p < 0.01 ) . After PVAI , three patients had recurrent paroxysmal AF , and two had atrial tachycardia , whereas after PVAI + CS , three patients had recurrent paroxysmal AF , and seven had atrial tachycardia . All patients in the PVAI + CS group with atrial tachycardia who underwent a second procedure were found to have peri-mitral macro-reentry as the underlying mechanism . Eighty-one percent of patients remained arrhythmia free off medication after 1.09 procedures in the PVAI group vs. 80 % after 1.35 procedures in the PVAI + CS group ( p < 0.01 ) . Conclusion The addition of limited ablation along the inferoposterior left atrium and within the adjacent coronary sinus to PVAI alone did not reduce the recurrence rate of paroxysmal atrial fibrillation and was associated with an increased rate of peri-mitral macro-reentrant atrial tachycardia BACKGROUND Atrial fibrillation ( AF ) is a very common cardiac arrhythmia , and is associated with an increased mortality in patients with hypertension . Whether the best therapeutic approach for these patients is to restore sinus rhythm ( SR ) or to adequately control the ventricular rate is still controversial . The aim of this study is to compare both strategies in patients with hypertension . METHODS AND RESULTS Two hundred and twenty-one patients with hypertension and AF of duration > 48 h were r and omly assigned to either the rhythm ( n=155 ) or rate ( n=66 ) control group . Exercise capacity was improved in the rhythm control group in the 1st year of the study ( p<0.0001 ) . There were no statistically significant differences in the embolic event rate and the total mortality between the 2 groups at the end of the study ( p = NS ) . CONCLUSIONS Although restoring and maintaining SR had a beneficial effect on exercise capacity in patients with hypertension and AF , no significant difference was found in terms of the total mortality and the embolic event rates . Thus , rate control is an acceptable primary strategy in patients with AF and hypertension OBJECTIVES This study examined the relative merits of digoxin , carvedilol , and their combination for the management of patients with atrial fibrillation ( AF ) and heart failure ( HF ) . BACKGROUND In patients with AF and HF , both digoxin and beta-blockers reduce the ventricular rate , and both may improve symptoms , but only beta-blockers have been shown to improve prognosis . If combined therapy is not superior to beta-blockers alone , treatment of patients with HF and AF could be simplified by stopping digoxin . METHODS We enrolled 47 patients ( 29 males ; mean age 68 years ) with persistent AF and HF ( mean left ventricular ejection fraction [ LVEF ] 24 % ) in a r and omized , double-blinded , placebo-controlled study . In the first phase of the study , digoxin was compared with the combination of digoxin and carvedilol ( four months ) . In the second phase , digoxin was withdrawn in a double-blinded manner in the carvedilol-treated arm , thus allowing a comparison between digoxin and carvedilol ( six months ) . Investigations were undertaken at baseline and at the end of each phase . RESULTS Compared with digoxin alone , combination therapy lowered the ventricular rate on 24-h ambulatory electrocardiographic monitoring ( p < 0.0001 ) and during submaximal exercise ( p < 0.05 ) , whereas LVEF ( p < 0.05 ) and symptom score ( p < 0.05 ) improved . In phase 2 , there was no significant difference between digoxin alone and carvedilol alone in any variable . The mean ventricular rate rose and LVEF fell when patients switched from combination therapy to carvedilol alone . Six-minute walk distance was not significantly influenced by any therapy . CONCLUSIONS The combination of carvedilol and digoxin appears generally superior to either carvedilol or digoxin alone in the management of AF in patients with HF BACKGROUND There are no reports describing the technique , electrophysiological evaluation , and clinical consequences of complete linear block at roofline joining the superior pulmonary veins ( PVs ) in patients with paroxysmal atrial fibrillation ( AF ) . METHODS AND RESULTS Ninety patients with drug-refractory paroxysmal AF undergoing radiofrequency ablation  were prospect ively r and omized into 2 ablation strategies : ( 1 ) PV isolation ( n=45 ) or ( 2 ) PV isolation in combination with linear ablation joining the 2 superior PVs ( roofline ; n=45 ) . In both groups , the cavotricuspid isthmus , fragmented peri-PV-ostial electrograms , and spontaneous non-PV foci were ablated . Roofline ablation was performed at the most cranial part of the left atrium ( LA ) with complete conduction block demonstrated during LA appendage pacing by the online mapping of continuous double potential and an activation detour propagating around the PVs to activate caudocranially the posterior wall of the LA . The effect of ablation at the LA roof was evaluated by the change in fibrillatory cycle length , termination and noninducibility of AF , and clinical outcome . PV isolation was achieved in all patients with no significant differences in the radiofrequency duration , fluoroscopy , or procedural time between the groups . Roofline ablation required 12+/-6 ( median 11 , range 3 to 25 ) minutes of radiofrequency energy delivery with a fluoroscopic duration of 7+/-2 minutes and was performed in 19+/-7 minutes . Complete block was confirmed in 43 patients ( 96 % ) and result ed in an activation delay that was shorter circumventing the left than the right PVs during LA appendage pacing ( 138+/-15 versus 146+/-25 ms , respectively ; P=0.01 ) . Roofline ablation result ed in a significant increase in the fibrillatory cycle length ( 198+/-38 to 217+/-44 ms ; P=0.0005 ) , termination of arrhythmia in 47 % ( 8/17 ) , and subsequent noninducibility of AF in 59 % ( 10/17 ) of the patients inducible after PV isolation . However , LA flutter , predominantly perimitral , could be induced in 10 patients ( 22 % ) after roofline ablation . At 15+/-4 months , 87 % of the roofline group and 69 % with PV isolation alone are arrhythmia free without antiarrhythmics ( P=0.04 ) . CONCLUSIONS This prospect i ve r and omized study demonstrates the feasibility of achieving complete linear block at the LA roof . Such ablation result ed in the prolongation of the fibrillatory cycle , termination of AF , and subsequent noninducibility and is associated with an improved clinical outcome compared with PV isolation alone Objective : To compare the efficacy of cardioversion in patients with atrial fibrillation between monophasic damped sine waveform and rectilinear biphasic waveform shocks at a high initial energy level and with a conventional paddle position . Design : Prospect i ve r and omised study . Patients and setting : 227 patients admitted for cardioversion of atrial fibrillation to a tertiary referral centre . Results : 70 % of 109 patients treated with an initial 200 J monophasic shock were cardioverted to sinus rhythm , compared with 80 % of 118 patients treated with an initial 120 J biphasic shock ( NS ) . After the second shock ( 360 J monophasic or 200 J biphasic ) , 90 % of the patients were in sinus rhythm in both groups . The mean cumulative energy used for successful cardioversion was 306 J for monophasic shocks and 159 J for biphasic shocks ( p < 0.001 ) . Conclusions : A protocol using monophasic waveform shocks in a 200–360 J sequence has the same efficacy ( 90 % ) as a protocol using rectilinear biphasic waveform shocks in a 120–200 J sequence . This equal efficacy is achieved with a significantly lower mean delivered energy level using the rectilinear biphasic shock waveform . The potential advantage of lower energy delivery for cardioversion of atrial fibrillation needs further study Background — Pulmonary vein ( PV ) isolation is a promising new treatment for  atrial fibrillation ( AF ) . We hypothesized that isolation of large areas around both ipsilateral PVs with verification of conduction block is more effective than the isolation of each individual PV . Methods and Results — A total of 110 patients , 67 with paroxysmal AF and 43 with persistent AF , were r and omly assigned to undergo either isolation of each individual PV or isolation of large areas around both ipsilateral PVs . The isolation of each individual PV was an electrophysiologically guided , ostial segmental ablation with a 64-pole basket catheter or a 20-pole circular mapping catheter ( group I ) . Isolation of large areas was performed around the 2 ipsilateral veins with a nonfluoroscopic navigation system and a circular 20-pole mapping catheter for verification of conduction block ( group II ) . In both groups , an irrigated-tip ablation catheter ( 25 to 35 W ) was used to achieve complete isolation . Procedure and ablation times were longer in group II , whereas fluoroscopic time was significantly shorter ( P≤0.001 ) . After a follow-up period of 15±4 months , 27 patients in group I ( 49 % ) and 37 patients in group II ( 67 % ) remained free of symptoms of AF and had no AF or atrial flutter during repetitive Holter monitoring without antiarrhythmic drug treatment after a single procedure ( P≤0.05 ) . Conclusions — The rate of success was significantly higher and fluoroscopy times were significantly lower in the group with large isolation areas around both ipsilateral PVs than in those who underwent individual PV isolation OBJECTIVES This study sought to assess the impact of rhythm- versus rate-control treatment strategies and of underlying rhythm on quality of life and functional capacity in patients with atrial fibrillation ( AF ) and congestive heart failure ( CHF ) . BACKGROUND Although intention-to-treat and efficacy analyses have demonstrated similar cardiovascular outcomes in patients with AF and CHF r and omized to rhythm or rate control , effects on quality of life remain to be determined . METHODS The AF-CHF ( Atrial Fibrillation and Congestive Heart Failure ) trial r and omized 1,376 patients to rhythm- or rate-control strategies .  For this pre-specified sub study , Medical Outcomes Short Form-36 question naires were administered at baseline and 4 months . Six-min walk tests were conducted at baseline , 3 weeks , 4 months , and 1 year . RESULTS Quality of life improved across all domains to a similar extent with rhythm and rate control . However , a higher proportion of time spent in sinus rhythm was associated with a modestly greater improvement in quality of life scores . Six-min walk distance ( p = 0.2328 ) and New York Heart Association functional class ( p = 0.1712 ) improved to a similar degree with rhythm and rate control . A higher proportion of time spent in sinus rhythm was associated with a greater improvement in New York Heart Association functional class ( p < 0.0001 ) but not in 6-min walk distance ( p = 0.1308 ) . CONCLUSIONS Improvements in quality of life and functional capacity were similar in patients with AF and CHF r and omized to rhythm- versus rate-control strategies . By contrast , sinus rhythm was associated with beneficial effects on New York Heart Association functional class and modest gains in quality of life . ( Atrial Fibrillation and Congestive Heart Failure [ AF-CHF ] ; NCT88597077 ) Rate control of atrial fibrillation ( AF ) is a main treatment modality . However , data are scarce on the relative efficacy of calcium channel blockers and β blockers or between drugs within each class . The purpose of the present study was to compare the effect of 4 rate-reducing , once-daily drug regimens on the ventricular heart rate and arrhythmia-related symptoms in patients with permanent AF . We included 60 patients ( mean age 71 ± 9 years , 18 women ) with permanent AF in an investigator-blind cross-over study . Diltiazem 360 mg/day , verapamil 240 mg/day , metoprolol 100 mg/day , and carvedilol 25 mg/day were administered for 3 weeks in a r and omized sequence . The 24-hour heart rate was measured using Holter monitoring , and arrhythmia-related symptoms were assessed using the Symptom Checklist question naire before r and omization and on the last day of each treatment period . The 24-hour mean heart rate was 96 ± 12 beats/min at baseline ( no treatment ) , 75 ± 10 beats/min with diltiazem , 81 ± 11 beats/min with verapamil , 82 ± 11 beats/min with metoprolol , and 84 ± 11 beats/min with carvedilol . All drugs reduced the heart rate compared to baseline ( p < 0.001 for all ) . The 24-hour heart rate was significantly lower with diltiazem than with any other drug tested ( p < 0.001 for all ) . Compared to baseline , diltiazem significantly reduced both the frequency ( p < 0.001 ) and the severity ( p = 0.005 ) of symptoms . In contrast , verapamil reduced symptom frequency only ( p = 0.012 ) . In conclusion , diltiazem 360 mg/day was the most effective drug regimen for reducing the heart rate in patients with permanent AF . Arrhythmia-related symptoms were reduced by treatment with the calcium channel blockers diltiazem and verapamil , but not by the β blockers AIMS The efficacy of epicardial left atrial ( LA ) cryoablation in eliminating  atrial fibrillation ( AF ) in patients undergoing mitral valve surgery ( MVS ) is unknown . We hypothesized that MVS combined with LA cryoablation is superior to MVS alone . METHODS AND RESULTS Sixty-nine patients with permanent AF , included at four centres , underwent MVS with or without epicardial LA cryoablation . The primary endpoint was regained sinus rhythm . Risk factors for failed AF cryoablation were eluci date d. Sixty-five out of 69 patients reached the primary endpoint . At 6 and 12 months follow-up , 73.3 % of patients who underwent cryoablation had regained sinus rhythm at both follow-ups , compared with 45.7 and 42.9 % of patients , respectively , who underwent MVS alone ( group differences , at 6 months P = 0.024 , after 12 months P = 0.013 ) . The in-hospital complication rate was 11.4 % in the MVS group and 26.5 % in the cryoablation group ( P = 0.110 ) . Risk factors for failed elimination of AF by cryoablation were duration of permanent AF ( P = 0.012 ) and presence of coronary artery disease ( P = 0.047 ) , according to multiple logistic regression analysis . CONCLUSION This first prospect i ve r and omized study showed that combining MVS with epicardial LA cryoablation is significantly better in eliminating pre-operative permanent AF than MVS alone AIMS It is well established in transthoracic ventricular defibrillation that biphasic truncated waveform shocks are associated with superior defibrillation efficacy when compared with damped sine wave monophasic waveform shocks . The aim of this study was to explore whether biphasic waveform shocks were superior to monophasic waveform shocks for external cardioversion of atrial fibrillation ( AF ) . METHODS AND RESULTS Fifty-seven patients in whom cardioversion of AF was indicated were r and omized in this prospect i ve study , to transthoracic cardioversion  with either monophasic damped sine waveform shocks or biphasic impedance compensating waveform shocks . In the group r and omized to monophasic waveform shocks ( 27 patients ) , a first shock of 150 J was delivered , followed ( if necessary ) by a 360 J shock . In the biphasic waveform group ( 30 patients ) , the first shock had an energy of 150 J and ( if necessary ) a second 150 J was delivered . All shocks were delivered in the anterolateral chest pad position . Sinus rhythm was restored in 16 patients ( 51 % ) with the first monophasic shock and in 27 patients ( 86 % ) with the first biphasic shock . The difference was statistically significant ( P=0.02 ) . After the second shock , sinus rhythm was obtained in a total of 24 patients ( 88 % ) with monophasic shocks and in 28 patients ( 93 % ) with biphasic shocks .  No complication was observed in either group and cardiac enzymes ( CK , CKmb , troponin I , myoglobin ) did not show any significant changes . CONCLUSION This study suggests that at the same energy level of 150 J , biphasic impedance compensating waveform shocks are superior to monophasic damped sine waveform shocks cardioversion of atrial fibrillation OBJECTIVE The aim of this study was to compare , in patients with permanent atrial fibrillation ( AF ) , the efficacy and safety of left atrial ablation with that of a biatrial procedure and to assess the risk factors for late failure of sinus rhythm restoration . METHODS Between January 2004 and January 2007 , 299 consecutive patients underwent the radiofrequency ablation procedure for AF associated with concomitant cardiac surgery .  According to a prospect i ve , open , and r and omized trial , 149 patients underwent left atrial plus cavotricuspid isthmus ablation  ( left atrial group ) , while 150 patients underwent biatrial ablation  ( biatrial group ) . The postoperative and mid-term follow-up results were compared between the two groups . Both univariate and multivariate analyses were used to assess the risk factors for late recurrence of AF . RESULTS There were seven in-hospital deaths ( 2.3 % ) , including two in the left atrial group ( 1.3 % ) and five in the biatrial group ( 3.3 % ) , and there were no differences in the incidence of the mortality and complications during the postoperative and follow-up periods between the groups . At discharge , sinus rhythm was maintained in 77.1 % of the patients , including 78.2 % of those in the left atrial group and 75.9 % in the biatrial group ( p=0.68 ) . Follow-up was completed in 97 % of the patients , with a mean time of 28+/-5 months . At the latest follow-up , two deaths occurred in the biatrial group . Sinus rhythm was documented in 237 ( 85.0 % ) out of all the patients , including 85.2 % ( 121/142 ) in the left atrial group and 84.1 % ( 116/138 ) in the biatrial group patients ( p=0.87 ) . Using a multivariate analysis , a left atrial diameter of > /=80 mm ( p=0.02 ) was an independent predictor for a late recurrence of AF . CONCLUSIONS Both the left atrial combined with cavotricuspid isthmus ablation and biatrial maze procedure is safe and effective in treating patients with AF , with an acceptable sinus conversion rate , mortality and morbidity . A left atrial dimension of > /=80 mm was a significant predictor for a late recurrence of AF OBJECTIVES This study sought to assess the safety and effectiveness of a novel cryoballoon ablation technology design ed to achieve single-delivery pulmonary vein ( PV ) isolation . BACKGROUND St and ard radiofrequency ablation is effective in eliminating atrial fibrillation ( AF ) but requires multiple lesion delivery at the risk of significant complications . METHODS Patients with documented symptomatic paroxysmal AF and previously failed therapy with ≥ 1 membrane active antiarrhythmic drug underwent 2:1 r and omization to either cryoballoon ablation ( n = 163 ) or drug therapy ( n = 82 ) . A 90-day blanking period allowed for optimization of antiarrhythmic drug therapy and reablation if necessary . Effectiveness of the cryoablation procedure versus drug therapy was determined at 12 months . RESULTS Patients had highly symptomatic AF ( 78 % paroxysmal , 22 % early persistent ) and experienced failure of at least one antiarrhythmic drug . Cryoablation produced acute isolation of three or more PVs in 98.2 % and all four PVs in 97.6 % of patients . PVs isolation was achieved with the balloon catheter alone in 83 % . At 12 months , treatment success was 69.9 % ( 114 of 163 ) of cryoblation patients compared with 7.3 % of antiarrhythmic drug patients ( absolute difference , 62.6 % [ p < 0.001 ] ) . Sixty-five ( 79 % ) drug-treated patients crossed over to cryoablation during 12 months of study follow-up due to recurrent , symptomatic AF , constituting drug treatment failure . There were 7 of the result ing 228 cryoablated patients ( 3.1 % ) with a > 75 % reduction in PV area during 12 months of follow-up . Twenty-nine of 259 procedures ( 11.2 % ) were associated with phrenic nerve palsy as determined by radiographic screening ; 25 of these had resolved by 12 months . Cryoablation patients had significantly improved symptoms at 12 months . CONCLUSIONS The STOP AF trial demonstrated that cryoballoon ablation is a safe and effective alternative to antiarrhythmic medication for the treatment of patients with symptomatic paroxysmal AF , for whom at least one antiarrhythmic drug has failed , with risks within accepted st and ards for ablation therapy . ( A Clinical Study of the A rct ic Front Cryoablation Balloon for the Treatment of Paroxysmal Atrial Fibrillation [ Stop AF ] ; NCT00523978 ) CONTEXT Treatment with antiarrhythmic drugs and anticoagulation is considered first-line therapy in patients with symptomatic atrial fibrillation ( AF ) .  Pulmonary vein isolation ( PVI ) with radiofrequency ablation may cure AF , obviating the need for antiarrhythmic drugs and anticoagulation . OBJECTIVE To determine whether PVI is feasible as first-line therapy for treating patients with symptomatic AF . DESIGN , SETTING , AND PARTICIPANTS A multicenter prospect i ve r and omized study conducted from December 31 , 2001 , to July 1 , 2002 , of 70 patients aged 18 to 75 years who experienced monthly symptomatic AF episodes for at least 3 months and had not been treated with antiarrhythmic drugs . INTERVENTION Patients were r and omized to receive either PVI using radiofrequency ablation ( n=33 ) or antiarrhythmic drug treatment ( n=37 ) , with a 1-year follow-up . MAIN OUTCOME MEASURES Recurrence of AF , hospitalization , and quality of life assessment . RESULTS Two patients in the antiarrhythmic drug treatment group and 1 patient in the PVI group were lost to follow-up . At the end of 1-year follow-up , 22 ( 63 % ) of 35 patients who received antiarrhythmic drugs had at least 1 recurrence of symptomatic AF compared with 4 ( 13 % ) of 32 patients who received PVI ( P<.001 ) . Hospitalization during 1-year follow-up occurred in 19 ( 54 % ) of 35 patients in the antiarrhythmic drug group compared with 3 ( 9 % ) of 32 in the PVI group ( P<.001 ) . In the antiarrhythmic drug group , the mean ( SD ) number of AF episodes decreased from 12 ( 7 ) to 6 ( 4 ) , after initiating therapy ( P = .01 ) . At 6-month follow-up , the improvement in quality of life of patients in the PVI group was significantly better than the improvement in the antiarrhythmic drug group in 5 subclasses of the Short-Form 36 health survey . There were no thromboembolic events in either group . Asymptomatic mild or moderate pulmonary vein stenosis was documented in 2 ( 6 % ) of 32 patients in the PVI group . CONCLUSION Pulmonary vein isolation appears to be a feasible first-line approach for treating patients with symptomatic AF . Larger studies are needed to confirm its safety and efficacy Background : Patients with rheumatic heart disease with atrial fibrillation incur significant morbidity and mortality . Which approach , ventricular rate control or maintenance of sinus rhythm , in this setting might be superior is not known . The role of amiodarone in this patient population for maintaining sinus rhythm has not been evaluated . Methods and Results : We prospect ively studied 144 patients with chronic rheumatic atrial fibrillation in a double-blind protocol in which rhythm control ( group I ) , comprising 48 patients each with amiodarone ( group Ia ) and placebo ( group Ib ) , were compared with each other and with patients in a ventricular rate control group ( group II ) in which the effects by diltiazem were determined ( n = 48 , open-label ) . Direct current cardioversion was attempted in group I. The mean age of the study population was 38.6 ± 10.3 years , left atrial size , 4.7 ±0.6 cm ; atrial fibrillation duration , 6.1 ± 5.4 years ; and 72.9 % had valvular interventions performed . At 1 year , 45 patients with sinus rhythm in group I compared with 48 in group II demonstrated an increase in exercise time ( 2.6 ± 1.9 vs. 0.6 ± 2.5 min , P = .001 ) , improvement in New York Heart Association class of 1 or more ( P = .002 ) , and improvement in the quality -of-life score of one or greater ( P = 0.01 ) with no difference in hospitalizations , systemic bleeds , or thromboembolism . Five patients died in group II ; none died in group I ( P = .02 ) . In group I , 73 of 87 ( 83.9 % ) patients converted to sinus rhythm and 45 of 86 ( 52.3 % ) patients maintained the rhythm at 1 year . Conversion rates were 38 of 43 ( 88.4 % ) with amiodarone versus 34 of 44 ( 77.3 % ) with placebo ( P = .49 ) ; the corresponding rate for maintaining sinus rhythm was 29 of 42 ( 69.1 % ) versus 16 of 44 ( 36.4 % ) ( P = .008 ) . A larger number of electrical cardioversions were required in the placebo group ( 2.1 vs. 1.4 , P = .011 ) . Conclusions : Maintenance of sinus rhythm is superior to ventricular rate control in patients with rheumatic atrial fibrillation with respect to effects on exercise capacity , quality of life , morbidity , and possibly mortality . Sinus rhythm could be restored in most patients , and amiodarone was superior to placebo in the restoration and maintenance of sinus rhythm BACKGROUND Pulmonary veins ( PVs ) have been shown to represent the most frequent sites of ectopic beats initiating paroxysmal atrial fibrillation ( AF ) . However , additional non-PV triggers , arising from different areas , have been reported as well . One of the most common non-PV sites described is the superior vena cava . AIMS The purpose of the study was to investigate the impact result ing from the systematic isolation of the superior vena cava ( SVCI ) in addition to pulmonary vein antrum isolation ( PVAI ) on the outcome of paroxysmal , persistent , and permanent AF ablation . METHODS A total of 320 consecutive patients who had been referred to our center in order to undergo a first attempt of AF ablation were r and omized into 2 groups . Group I ( 160 patients ) underwent PVAI only ; Group II ( 160 patients ) underwent PVAI and SVCI . RESULTS AF was paroxysmal in 134 ( 46 % ) , persistent in 75 ( 23 % ) , and permanent in 111 ( 31 % ) of said patients . SVCI was performed on 134 of the 160 patients ( 84 % ) in Group II . SVC isolation was not performed on the remaining 26 patients either because of phrenic nerve capture or the lack of SVC potentials . Comparison of the outcome data between the 2 groups , after a follow-up of 12 months , revealed a significant difference in total procedural success solely with patients manifesting paroxysmal atrial fibrillation ( 56/73 [ 77 % ] Group I vs. 55/61 [ 90 % ] Group II ; P = 0.04 ; OR 2.78 ) . CONCLUSIONS In our study , the strategy of the empiric SVCI in addition to PVAI has improved the outcome of AF ablation solely in patients manifesting paroxysmal AF BACKGROUND Left atrial ( LA ) circumferential ablation has been reported to eliminate atrial fibrillation ( AF ) . Whether an ablation without encirclement of the pulmonary veins ( PVs ) is as effective as LA circumferential ablation is not clear . OBJECTIVES The purpose of this study was to compare the efficacy of LA circumferential ablation and nonencircling linear ablation in patients with chronic AF . METHODS Eighty patients with chronic AF were r and omized to undergo LA circumferential ablation ( n = 40 ) or nonencircling linear ablation ( n = 40 ) . In LA circumferential ablation , the PVs were encircled , with additional lines made in the mitral isthmus and posterior wall or roof . In nonencircling linear ablation , 4 + /- 1 ablation lines were created through areas of complex electrograms , with lines in the roof ( 38 ) , anterior wall ( 36 ) , septum ( 40 ) , mitral isthmus ( 32 ) , and posterior annulus ( 6 ) . The endpoint of LA circumferential ablation and nonencircling linear ablation was voltage abatement . RESULTS LA flutter occurred in 15 % after LA circumferential ablation and in 18 % after nonencircling linear ablation ( P = .8 ) . A repeat ablation procedure was performed for recurrent AF in 7 and 11 patients or for atrial flutter in 6 and 4 patients after LA circumferential ablation and nonencircling linear ablation , respectively ( P = .8 ) . At 9 + /- 4 months , the prevalence of AF was 28 % in the LA circumferential ablation and 25 % in the nonencircling linear ablation group ( P = .8 ) . Sixty-eight percent and 60 % of patients were in sinus rhythm and free of AF and atrial flutter in the absence of antiarrhythmic drug therapy after LA circumferential ablation and nonencircling linear ablation , respectively ( P = .5 ) . There were no complications . CONCLUSION Nonencircling linear ablation and LA circumferential ablation are equally efficacious in eliminating chronic AF . However , the advantage of nonencircling linear ablation is that it eliminates the need for ablation along the posterior wall of the LA . Therefore , nonencircling linear ablation may avoid the small but real risk of atrioesophageal fistula formation associated with LA circumferential ablation BACKGROUND This prospect i ve multicenter r and omized study aim ed to compare the efficacy of 3 common ablation methods used for longst and ing permanent atrial fibrillation ( AF ) . METHODS A total of 144 patients with longst and ing permanent AF ( median duration 28 months ) were r and omly assigned to circumferential pulmonary vein ablation ( CPVA , group 1 , n = 47 ) , to pulmonary vein antrum isolation ( PVAI , group 2 , n = 48 ) or to a hybrid strategy combining ablation of complex fractionated or rapid atrial electrograms ( CFAE ) in both atria followed by a pulmonary vein antrum isolation ( CFAE + PVAI , group 3 , n = 49 ) . RESULTS Scarring in the left atrium and structural heart disease/hypertension were present in most patients ( 65 % ) . After a mean follow-up of 16 months , 11 % of patients in group 1 , 40 % of patients in group 2 and 61 % of patients in group 3 were in sinus rhythm after one procedure and with no antiarrhythmic drugs ( P < .001 ) . Sinus rhythm maintenance would increase respectively to 28 % ( group 1 ) , 83 % ( group 2 ) , and 94 % ( group 3 ) after 2 procedures and with antiarrhythmic drugs ( AADs , P < .001 ) . The AF terminated during ablation , either by conversion to sinus rhythm or organization into an atrial tachyarrhythmia , in 13 % of patients ( group 1 ) , 44 % ( group 2 ) , and 74 % ( group 3 ) respectively . CFAE alone , performed as the first step of the ablation in group 3 , organized AF in only 1 patient . CONCLUSION In this study , the hybrid AF ablation strategy including antrum isolation and CFAE ablation had the highest likelihood of maintaining sinus rhythm in patients with longst and ing permanent AF . Electrical isolation of the PVs , although inadequate if performed alone , is relevant to achieve long-term sinus rhythm maintenance after ablation . Bi-atrial CFAE ablation had a minimal impact on AF termination during ablation STUDY OBJECTIVES To compare the efficacy and safety of amiodarone and propafenone when used for the prevention of  atrial fibrillation ( AF ) and maintenance of normal sinus rhythm in patients with refractory AF . DESIGN Prospect i ve , r and omized , single-blind trial . SETTING Tertiary cardiac referral center . PATIENTS One hundred forty-six consecutive patients ( 72 men ; mean age , 63 + /- 10 years [ + /- SD ] ) with recurrent symptomatic AF . INTERVENTIONS We studied 146 patients after restoration of sinus rhythm ; patients were r and omized to amiodarone , 200 mg/d , or propafenone , 450 mg/d . Follow-up clinical evaluations were conducted at the first , second , fourth , and sixth months , and at 3-month intervals thereafter . The proportion of patients relapsing to AF and /or experiencing side effects was calculated for each group using the Kaplan-Meier method . End point of the study was recurrence of AF or occurrence of side effects necessitating discontinuation of medication . MEASUREMENTS AND RESULTS Of 146 patients , 72 received amiodarone and 74 received propafenone . The two groups were clinical ly similar . Of the 72 patients receiving amiodarone , AF developed in 25 patients , after an average of 9.8 months , compared to 33 of the 74 patients receiving propafenone after an average of 3.8 months . Twelve patients receiving amiodarone and 2 patients receiving propafenone had side effects necessitating withdrawal of medication while still in sinus rhythm . CONCLUSIONS Amiodarone tends to be more effective than propafenone in maintaining sinus rhythm in patients with AF , but this advantage is offset by a higher incidence of side effects OBJECTIVE To assess and compare the safety and efficacy of amiodarone and sotalol in the treatment of patients with recurrent symptomatic atrial fibrillation . DESIGN Prospect i ve , r and omised , single blind , placebo controlled study . SETTING Tertiary cardiac referral centre . PATIENTS 186 consecutive patients ( 97 men , 89 women ; mean ( SD ) age , 63 ( 10 ) years ) with recurrent , symptomatic atrial fibrillation . INTERVENTIONS 65 patients were r and omised to amiodarone , 61 to sotalol , and 60 to placebo . Patients receiving amiodarone were maintained at a dose of 200 mg/day after a 30 day loading phase . The sotalol dose was 160 - 480 mg daily , as tolerated . MAIN OUTCOME MEASURES Recurrence of atrial fibrillation or side effects . RESULTS In the amiodarone group , 31 of the 65 patients developed atrial fibrillation after an average of six months , while 15 ( 11 in sinus rhythm and four in atrial fibrillation ) experienced significant side effects after an average of 16 months . In the sotalol group , relapse to atrial fibrillation occurred in 47 of the 61 patients after an average of eight months ; three experienced side effects during the titration phase . In the placebo group , 53 of the 60 patients developed atrial fibrillation after an average of four months ( p < 0.001 for amiodarone and sotalol v placebo ; p < 0.001 for amiodarone v sotalol ) . CONCLUSIONS Both amiodarone and sotalol can be used for the maintenance of normal sinus rhythm in patients with symptomatic atrial fibrillation .  Amiodarone is more effective but causes more side effects This report compares the cumulative efficacy of cardioversion and skeletal muscle injury after either damped sine wave monophasic or truncated exponential biphasic transthoracic cardioversion of persistent atrial fibrillation . The trial sought to refute the null hypothesis of therapeutic equivalence between monophasic and biphasic waveforms . Results of the study reveal similar cumulative efficacy of waveforms and greater levels of skeletal muscle damage when patients are younger and male , and when monophasic waveforms are used Objective To determine whether or not radiofrequency ablation ( RFA ) for persistent atrial fibrillation in patients with advanced heart failure leads to improvements in cardiac function . Setting Patients were recruited from heart failure outpatient clinics in Scotl and . Design and intervention Patients with advanced heart failure and severe left ventricular dysfunction were r and omised to RFA ( rhythm control ) or  continued medical treatment  ( rate control ) . Patients were followed up for a minimum of 6 months . Main outcome measure Change in left ventricular ejection fraction ( LVEF ) measured by cardiovascular MRI . Results 22 patients were r and omised to RFA and 19 to medical treatment . In the RFA group , 50 % of patients were in sinus rhythm at the end of the study ( compared with none in the medical treatment group ) . The increase in cardiovascular magnetic resonance ( CMR ) LVEF in the RFA group was 4.5±11.1 % compared with 2.8±6.7 % in the medical treatment group ( p=0.6 ) . The RFA group had a greater increase in radionuclide LVEF ( a prespecified secondary end point ) than patients in the medical treatment group ( + 8.2±12.0 % vs + 1.4±5.9 % ; p=0.032 ) . RFA did not improve N-terminal pro-B-type natriuretic peptide , 6 min walk distance or quality of life . The rate of serious complications related to RFA was 15 % . Conclusions RFA result ed in long-term restoration of sinus rhythm in only 50 % of patients . RFA did not improve CMR LVEF compared with a strategy of rate control . RFA did improve radionuclide LVEF but did not improve other secondary outcomes and was associated with a significant rate of serious complications . Clinical trials registration number NCT00292162 Background Various strategies have been used for atrial fibrillation ( AF ) ablation . It is unclear whether adding linear lesions to pulmonary vein ( PV ) isolation has significant advantages . Objectives We assessed the clinical benefit of adding linear lesions in patients undergoing PV isolation for AF . Methods One hundred patients ( 63 male and 37 female ; mean age of 59 ± 11 years ) with documented paroxysmal AF were included in the study . Patients were r and omized into two groups . The first group underwent PV isolation alone . The second group underwent PV isolation and had two linear lesions created ; one line between the superior PVs , and a second line from the left inferior PV to the mitral valve annulus . Patients ’ clinical progress after the ablation was evaluated and compared at 1 , 3 , and 9 months after their respective ablation procedures . Results The linear lesions group maintained sinus rhythm and had fewer symptoms than the lone PV isolation group ( 86 vs. 58 % , respectively ) ( p < 0.05 ) at 1 month . At 9 months , when patients who reverted to AF underwent additional management to regain sinus rhythm ( 90 vs. 82 % , respectively ) ( p = NS ) , there was no statistical difference between the groups regarding the use of antiarrhythmics , the need for electrical cardioversion , and subjective improvement . Conclusion The addition of linear lesions to PV isolation more effectively achieved sinus rhythm initially and fewer patients required additional management to maintain their rhythm when compared to patients who underwent lone PV isolation . However , at 9 months , the overall results were similar in both groups Background — The mainstay of treatment for atrial fibrillation ( AF ) remains pharmacological ; however , catheter ablation has increasingly been used over the last decade . The relative merits of each strategy have not been extensively studied . Methods and Results — We conducted a r and omized multicenter comparison of these 2 treatment strategies in patients with paroxysmal AF resistant to at least 1 antiarrhythmic drug . The primary end point was absence of recurrent AF between months 3 and 12 , absence of recurrent AF after up to 3 ablation procedures , or changes in antiarrhythmic drugs during the first 3 months . Ablation consisted of pulmonary vein isolation in all cases , whereas additional extrapulmonary vein lesions were at the discretion of the physician . Crossover was permitted at 3 months in case of failure . Echocardiographic data , symptom score , exercise capacity , quality of life , and AF burden were evaluated at 3 , 6 , and 12 months by the supervising committee . Of 149 eligible patients , 112 ( 18 women [ 16 % ] ; age , 51.1±11.1 years ) were enrolled and r and omized to ablation ( n=53 ) or “ new ” antiarrhythmic drugs alone or in combination ( n=59 ) . Crossover from the antiarrhythmic drugs and ablation groups occurred in 37 ( 63 % ) and 5 patients ( 9 % ) , respectively ( P=0.0001 ) . At the 1-year follow-up , 13 of 55 patients ( 23 % ) and 46 of 52 patients ( 89 % ) had no recurrence of AF in the antiarrhythmic drug and ablation groups , respectively ( P<0.0001 ) . Symptom score , exercise capacity , and quality of life were significantly higher in the ablation group . Conclusion — This r and omized multicenter study demonstrates the superiority of catheter ablation over antiarrhythmic drugs in patients with AF with regard to maintenance of sinus rhythm and improvement in symptoms , exercise capacity , and quality of life This prospect i ve , r and omized , single-blinded , placebo-controlled study compared the efficacy and safety of sotalol and propafenone when used for long-term prevention of  atrial fibrillation .  For the long-term maintenance of normal sinus rhythm , propafenone seems to be more effective than sotalol BACKGROUND Stepwise segmental pulmonary vein isolation ( SPVI ) and circumferential pulmonary vein isolation ( CPVI ) have been developed to treat patients with atrial fibrillation ( AF ) , but the preferable approach for paroxysmal AF ( PAF ) has not been established . METHODS AND RESULTS One hundred and ten patients with symptomatic PAF were r and omized into a stepwise SPVI group ( n=55 ) or CPVI group ( n=55 ) . Systemic SPVI combined with left atrial linear ablation tailored by inducibility of AF was performed in the stepwise SPVI group . Circumferential linear ablation around the left and right-sided pulmonary veins ( PVs ) guided by 3-dimensional electroanatomic mapping was performed in the CPVI group . The endpoints of ablation are non-induciblity of AF in the stepwise SPVI group and continuity of circular lesions combined with PV isolation in the CPVI group . After the initial procedures , atrial tachyarrhythmis ( ATa ) recurred within the first 3 months in 23 of the 55 patients ( 41.8 % ) who underwent stepwise SPVI and in 20 of the 55 patients ( 36.4 % ) who had CPVI ( p=0.69 ) . Repeat procedures were performed in 7 patients from the stepwise SPVI group and 5 from the CPVI group ( p=0.76 ) . During the 3 - 9 months after the last procedure , 46 patients ( 83.6 % ) from the CPVI group and 43 ( 78.2 % ) from the stepwise SPVI group did not have symptomatic ATa while not taking anti-arrhythmic drugs ( p=0.63 ) . Severe subcutaneous hematoma or PV stenosis occurred in 3 patients . CONCLUSIONS The efficacy of stepwise SPVI is comparable to that of CPVI for patients with PAF Background —Although the Cox-Maze III procedure is effective for treating permanent atrial fibrillation ( AF ) , its high complexity limits its use . The Saline-Irrigated Cooled-tip Radiofrequency Ablation ( SICTRA ) System is an alternative source of energy used to ablate AF . The aim of this study was to evaluate the effectiveness of the SICTRA for the treatment of permanent AF in patients with rheumatic mitral valve ( MV ) disease . Methods and Results —Between February 2002 and April 2003 , 70 patients with permanent AF and rheumatic MV disease were r and omly assigned to undergo a modified Maze III procedure using SICTRA associated with MV surgery ( group A ) or MV surgery alone ( group B ) . Groups A and B were similar in terms of baseline characteristics . The in-hospital mortality rate was 2.3 % ( 1 death ) in group A versus 0 % ( no deaths ) in group B ( P>0.99 ) . The additional time required for the left-sided radiofrequency ablation in group A was 14.2±5.1 minutes and for right-sided ablation was 12.3±4.2 minutes . The mean postoperative follow-up periods were 13.8±3.4 and 11.5±7.3 months , respectively , in groups A and B. The overall mid-term survival rate was 95.1 % in group A and 92.8 % in group B ( P>0.99 ) . The cumulative rates of sinus rhythm were 79.4 % in group A and 26.9 % in group B ( P=0.001 ) . Doppler echocardiography documented biatrial transport function in 90.3 % of group A patients in sinus rhythm . Conclusions —The SICTRA is effective for treating permanent AF associated with rheumatic MV disease Background —The study was conducted to compare relative safety and efficacy of pulmonary vein antrum isolation ( PVAI ) using intracardiac echocardiographic guidance and circumferential pulmonary vein ablation ( CPVA ) for atrial fibrillation ( AF ) using radiofrequency energy . Methods and Results —Sixty patients ( 81 % men ; 81 % paroxysmal ; age , 56±8 years ) failing 2±1 antiarrhythmic drugs were r and omly assigned to undergo CPVA ( n=30 ) or PVAI ( n=30 ) at 5 centers between December 2004 and October 2007 .  CPVA patients had circular lesions placed at least 1 cm outside of the veins . Ipsilateral veins were ablated en block with the end point of disappearance of potentials within the circular lesion . Left atrial roof line and mitral isthmus line were ablated without verification of block . For patients in AF postablation or with AF induced with programmed stimulation , complex fractionated electrograms were mapped and ablated to the end point of AF termination or disappearance of complex fractionated electrograms . PVAI did not include complex fractionated electrogram ablation . Esophageal temperature was monitored and kept within 2 ° C of baseline or under 39 ° C . Success was defined as absence of atrial tachyarrhythmias ( AF/AT ) off antiarrhythmic drugs . There was no difference between CPVA and PVAI regarding to baseline variables , catheter used , duration of the procedure , or RF delivery . Fluoroscopy time was longer with PVAI ( 54±17 minutes versus 77±18 minutes , P=0.0001 ) . No significant complications occurred in either arm . PVAI was more likely to achieve control of AF/AT off antiarrhythmic drugs ( 57 % versus 27 % , P=0.02 ) at 2±1 years of follow-up . Conclusions —A single PVAI procedure is more likely to result in freedom from AF/AT off antiarrhythmic drugs than CPVA supplemented by complex fractionated electrogram ablation in select patients Objective : Microwave ablation in conjunction with open heart surgery is effective in restoring sinus rhythm ( SR ) in patients with atrial fibrillation ( AF ) . In patients assigned for isolated mitral valve surgery no prospect i ve r and omized trial has reported its efficacy . Methods : 70 patients with longlasting AF where included from 5 different centres . They were r and omly assigned to mitral valve surgery and atrial microwave ablation or mitral valve surgery alone . Results : Out of 70 r and omized , 66 and 64 patients were available for evaluation at 6 and 12 months . At 12 months SR was restored and preserved in 71.0 % in the ablation group vs 36.4 % in the control group ( P=0.006 ) , corresponding figures at 6 months was 62.5 % vs 26.5 % ( P=0.003 ) . The 30-day mortality rate was 1.4 % , with one death in the ablation group vs zero deaths in the control group . At 12 months the mortality rate was 7,1 % ( Ablation n=3 vs Control n=2 ) . No significant differences existed between the groups with regard to the overall rate of serious adverse events ( SAE ) during the perioperative period or at the end of the study . 16 % of patients r and omized to ablation were on antiarrhytmic drugs compared to 6 % in the control group after 1 year ( p=0.22 ) . Conclusion : Microwave ablation of left and right atrium in conjunction with mitral valve surgery is safe and effectively restores sinus rhythm in patients with longlasting AF as compared to mitral valve surgery alone BACKGROUND Current atrial fibrillation ( AF ) ablation involves isolation of all pulmonary veins ( PVs ) with or without additional linear lesions . However , whether such extensive ablation is necessary is unclear . OBJECTIVE The purpose of this study was to assess the efficacy of different ablation strategies on long-term AF control . METHODS We prospect ively r and omized patients to undergo isolation of all versus arrhythmogenic PVs ( identified by st and ardized stimulation protocol ) .  PV isolation was guided by circular mapping catheter . The endpoint was entry/exit block persisting for > or = 20 minutes . Patients were evaluated at three clinic visits ( at 6 weeks , 6 months , and 1 year ) and multiple transtelephonic monitoring periods . Antiarrhythmic drugs were discontinued at 6 weeks . Primary study endpoint was long-term AF control ( freedom or > 90 % reduction in AF burden off or on previously ineffective antiarrhythmic drugs at 1 year after a single ablation procedure ) . RESULTS Over a 20-month period , 105 patients ( 76 men and 29 women , age 57 + /- 9 years ; paroxysmal AF = 77 ) were r and omized , and 103 patients completed 1-year follow-up ( 51 patients in all-PV arm , 52 patients in arrhythmogenic PV arm ) . The primary endpoint was achieved in 75 ( 73 % ) patients and was similar in patients r and omized to all-PV arm versus arrhythmogenic PV arm [ 38 ( 75 % ) patients vs 37 ( 71 % ) patients , respectively ; odds ratio 1.18 , 95 % confidence interval 0.50 , 2.83 , P = .70 ] . Secondary study endpoints , including freedom from AF off antiarrhythmic drugs , total procedure/fluoroscopy times , and occurrence of serious adverse events , were not different between the two groups . CONCLUSION In a r and omized comparison , isolation of arrhythmogenic veins was as efficacious as empiric isolation of all veins in achieving long-term AF control AIMS The purpose of the study was to compare the efficacy and safety of sotalol and bisoprolol in the maintenance of sinus rhythm after electrical cardioversion of atrial fibrillation . METHODS Patients ( n=128 ) were r and omized to sotalol ( 80 mg b.i.d . ) or bisoprolol ( 5 mg x day(-1 ) ) . Patients with contraindications to beta-blockers , class III antiarrhythmic drugs or prior treatment with use of study medication for prevention of atrial fibrillation were excluded . Follow-up clinical evaluation was performed 1 day and 1 month after cardioversion and thereafter at 3-month intervals . RESULTS There were no group differences in baseline clinical characteristics . After a follow-up of 12 months , 59 % of all patients were still in sinus rhythm . The fraction remaining in sinus rhythm was calculated for the two groups by Kaplan -- Meier analysis . During follow-up , 41 % of patients on sotalol and 42 % on bisoprolol developed atrial fibrillation ( ns ) . In two patients ( 3.1 % ) on sotalol , life-threatening proarrhythmias ( torsade de pointes tachycardias ) occurred , whereas none were found in the bisoprolol group . Symptomatic bradycardias occurred in two patients on sotalol and three on bisoprolol . CONCLUSION This study demonstrates that sotalol ( 160 mg x day(-1 ) ) and bisoprolol ( 5 mg x day(-1 ) ) are equally effective in maintaining sinus rhythm . Because of the side effects of sotalol , bisoprolol seems to be advantageous for maintenance of sinus rhythm after cardioversion of atrial fibrillation AIMS External electrical cardioversion is the method of choice to terminate persistent atrial fibrillation . Whether the type of shock electrode affects cardioversion success is not known . We tested whether h and -held steel electrodes improve cardioversion outcome with monophasic or biphasic shocks when compared with adhesive patch electrodes . METHODS AND RESULTS Two hundred and one consecutive patients with persistent atrial fibrillation ( 147 male , mean age 63+/-1 years , duration of atrial fibrillation 6.3+/-1 months ) were r and omly assigned to cardioversion using either a sinusoidal monophasic or a truncated exponential biphasic shock wave form . The first half of patients were cardioverted using adhesive patch electrodes , the second half using h and -held steel paddle electrodes , and all patients using an anterior-posterior electrode position . Paddle electrodes successfully cardioverted 100/104 patients ( 96 % ) and patch electrodes 85/97 patients ( 88 % , P=0.04 ) . This effect was comparable to that of biphasic shocks : biphasic shocks  cardioverted 102/104 patients ( 98 % ) and monophasic shocks 83/97 patients ( 86 % , P=0.001 ) . A beneficial effect of paddle electrodes was observed for both shock wave forms . After cross-over from an ineffective monophasic to a biphasic shock , cardioversion was successful in 198/201 ( 98.5 % ) patients . Unsuccessful cardioversion after cross-over ( 3/201 patients ) only occurred with patch electrodes ( P=0.07 ) . CONCLUSION H and -held paddle electrodes increase success of external cardioversion of atrial fibrillation in this trial . This increase is of similar magnitude as the increase in cardioversion success achieved with biphasic shocks . A combination of biphasic shocks , paddle electrodes , and an anterior-posterior electrode position renders outcome of external cardioversion almost always successful ( 104/104 patients in this trial ) OBJECTIVES The VERDICT ( Verapamil Versus Digoxin and Acute Versus Routine Serial Cardioversion Trial ) is a prospect i ve , r and omized study to investigate whether : 1 ) acutely repeated serial electrical cardioversions ( ECVs ) after a relapse of atrial fibrillation ( AF ) ; and 2 ) prevention of intracellular calcium overload by verapamil , decrease intractability of AF . BACKGROUND Rhythm control is desirable in patients suffering from symptomatic AF . METHODS A total of 144 patients with persistent AF were included . Seventy-four ( 51 % ) patients were r and omized to the acute ( within 24 h ) and 70 ( 49 % ) patients to the routine serial ECVs , and 74 ( 51 % ) patients to verapamil and 70 ( 49 % ) patients to digoxin for rate control before ECV and continued during follow-up ( 2 x 2 factorial design ) . Class III antiarrhythmic drugs were used after a relapse of AF . Follow-up was 18 months . RESULTS At baseline , there were no significant differences between the groups , except for beta-blocker use in the verapamil versus digoxin group ( 38 % vs. 60 % , respectively , p = 0.01 ) . At follow-up , no difference in the occurrence of permanent AF between the acute and the routine cardioversion groups was observed ( 32 % [ 95 % confidence intervals ( CI ) ] 22 to 44 ) vs. 31 % [ 95 % CI 21 to 44 ] , respectively , p = NS ) , and also no difference between the verapamil- and the digoxin-r and omized patients ( 28 % [ 95 % CI 19 to 40 ] vs. 36 % [ 95 % CI 25 to 48 ] respectively , p = NS ) . Multivariate Cox regression analysis revealed that lone digoxin use was the only significant predictor of failure of rhythm control treatment ( hazard ratio 2.2 [ 95 % CI 1.1 to 4.4 ] , p = 0.02 ) . CONCLUSIONS An acute serial cardioversion strategy does not improve long-term rhythm control in comparison with a routine serial cardioversion strategy . Furthermore , verapamil has no beneficial effect in a serial cardioversion strategy AIMS Activation of beta-adrenoceptors attenuates prolongation of action potential duration induced by blockade of the delayed rectifier potassium current . We examined whether acute administration of beta-blocker could enhance ibutilide ( IB ) efficacy in conversion of atrial fibrillation ( AF ) with a rapid ventricular rate . METHODS AND RESULTS Ninety patients ( aged 63 + /- 13.5 years ) with rapidly conducting AF were r and omized in to two groups . Group A ( n = 44 ) received esmolol titrated to achieve a heart rate of < 100 bpm followed by IB co-administration , while Group B ( n = 46 ) were treated with IB as monotherapy . In Group A , 29 patients ( 67 % ) converted to sinus rhythm ( SR ) compared with 21 ( 46 % ) in Group B ( P = 0.04 ) . The use of esmolol was the most important predictor for cardioversion ( P = 0.009 ) . The slower the heart rate at the time of IB initiation , the higher the likelihood for cardioversion ( P = 0.015 ) . Patients in Group A had significantly shorter corrected QT interval ( QTc ) at the time of conversion than those in Group B ( 433 vs. 501 ms , P = 0.003 ) . Two patients in Group A developed severe bradycardia , whereas three patients in Group B developed severe ventricular tachycardia ( VT ) . CONCLUSION Compared with IB monotherapy , the combination therapy of esmolol and IB appears to be more effective in conversion of rapidly conducting AF back to SR . The addition of beta-blocker reduces QTc prolongation and diminishes the risk of VT at the expense , however , of increased bradycardic events OBJECTIVE Biphasic waveforms have similar or greater efficacy at cardioverting atrial and ventricular arrhythmias at lower energy levels than monophasic waveforms , and cause less ST depression following defibrillation of ventricular fibrillation . No studies have investigated this effect on ST change with atrial arrhythmias . We studied the efficacy of the Welch Allyn-MRL PIC biphasic defibrillator . METHODS One hundred and thirty-nine patients undergoing elective DC cardioversion for atrial arrhythmias were r and omised to cardioversion by monophasic ( Hewlett Packard Codemaster XL ; 100 , 200 , 300 , 360 and 360J ) or biphasic ( Welch Allyn-MRL PIC ; 70 , 100 , 150 , 200 and 300J ) defibrillator . We analysed success of cardioversion after 0 and 30min , cumulative energy , number of shocks and energy at successful cardioversion . The ST change in the recorded electrocardiogram was measured at 15s after all shocks using electronic callipers . RESULTS Immediately after cardioversion 59/68 ( 86.8 % ) of the monophasic group versus 56/60 ( 93.3 % ) of the biphasic group were in sinus rhythm . Of the monophasic group , 55/67 ( 82.1 % ) remained in sinus rhythm at 30min versus 53/58 ( 91.4 % ) of the biphasic group . These differences were not significant at 0min ( P=0.35 ) or 30min ( P=0.21 ) . The biphasic group required significantly fewer shocks ( P=0.006 ) , less cumulative energy ( P<0.0001 ) and required lower total energy for successful cardioversion ( P<0.0001 ) . Of the 102 patients with electrocardiogram recordings suitable for analysis , ST segment change was greater in the monophasic group ( P=0.037 ) . CONCLUSIONS The Welch Allyn-MRL biphasic waveform for DC cardioversion results in fewer shocks , with less cumulative energy delivered and less post shock ST change than with a Hewlett Packard Codemaster XL damped sine wave monophasic waveform OBJECTIVE The aim of the study was to assess if the anterior-posterior electrode position for the conversion of atrial fibrillation using biphasic waveform shocks is more effective and needs less energy compared with the anterior-lateral position . BACKGROUND In several studies , anterior-posterior electrode position has been demonstrated to be superior to anterior-lateral position for the termination of atrial fibrillation using monophasic waveform shocks , but data regarding biphasic shocks are still emerging . PATIENTS AND METHODS Our prospect i ve , r and omized study enrolled 103 consecutive patients with atrial fibrillation who were referred for elective cardioversion .  The electrode position was r and omly selected to be anterior-lateral ( n=55 ) and anterior-posterior ( n=48 ) . A step-up protocol of 100 , 150 , 200 , and 300 J biphasic truncated exponential waveform shocks was used . RESULTS . Two groups with different paddle position were compared . There was no difference in age , gender , body mass index , ejection fraction , or left atrial size between the groups . Sinus rhythm restoration failed only in one patient in each group . Energy of 100 J was sufficiently effective in most patients in both groups . CONCLUSIONS The anterior-posterior electrode position during transthoracic cardioversion using biphasic waveform shocks has no advantages compared with more comfortable and common anterior-lateral position OBJECTIVES The Australian Intervention R and omized Control of Rate in Atrial Fibrillation Trial was a multicenter trial of atrioventricular junction ablation and pacing ( AVJAP ) compared with pharmacologic ventricular rate control ( medication [ MED ] ) in patients with mild to moderately symptomatic permanent atrial fibrillation ( AF ) . BACKGROUND There have been very few prospect i ve r and omized trials , undertaken in highly symptomatic patients , comparing AVJAP with pharmacologic methods of ventricular rate control for patients with permanent AF . METHODS There were 99 patients ( 70 men , mean age 68 + /- 8.6 years ) at five centers . Forty-nine patients were r and omized to AVJAP while 50 patients were r and omized to pharmacologic control . The primary end point was cardiac function measured by echocardiography and exercise tolerance . The secondary end points were ventricular rate control , evaluated by 24-h ambulatory electrocardiographic monitoring , and quality of life . Data were collected at r and omization and then at one month , six months , and 12 months post-r and omization . RESULTS At 12 months follow-up there was no significant difference in left ventricular ejection fraction ( AVJAP : 54 + /- 17 % ; MED : 61 + /- 13 % [ p = ns ] ) or exercise duration on treadmill testing ( AVJAP : 4.1 + /- 2 min ; MED : 4.6 + /- 2 min [ p = ns ] ) ; however , the peak ventricular rate was lower in the AVJAP group during exercise ( 112 + /- 17 beats/min vs. 153 + /- 36 beats/min , p < 0.05 ) and activities of daily life ( 117 + /- 16 beats/min vs. 152 + /- 37 beats/min , p < 0.05 ) . The CAST quality -of-life question naire revealed that patients in the AVJAP group had fewer symptoms at six months ( p = 0.003 ) and at 12 months ( p = 0.004 ) . The observed relative risk reduction in symptoms at 12 months was 18 % . Global subjective semiquantitative measurement of quality of life using the " ladder of life " revealed that the AVJAP group reported a 6 % better quality of life at six months ( p = 0.011 ) . CONCLUSIONS In this trial , AVJAP for patients with mild to moderately symptomatic permanent AF did not worsen cardiac function during long-term follow-up , and quality of life was improved AIM The aim of our study was to compare the efficacy and safety of ibutilide and amiodarone ( intravenously ) in converting  recent-onset atrial fibrillation ( AF ) and atrial flutter ( Af )  to sinus rhythm ( SR ) . METHODS The study was prospect i ve , r and omized and included 152 ( 103 men and 49 women ) consecutive patients with AF or Af of 3 - 48 h duration .  Ibutilide is a selective class III antiarrhythmic agent which when administered intravenously can terminate AF and Af .  Amiodarone is also a class III antiarrhythmic agent that when given intravenously or orally has proved to be more effective than other agents in terminating AF and Af [ B.N. Singh , F.V. Mody , B. Lopez , J.S. Sarma . Antiarrhythmic agents for atrial fibrillation : focus on prolonging atrial repolarization . Am J Cardiol 1999 Nov 4 ; 84 : 161R-173R . ] . Seventy-nine patients ( 56 with AF and 23 with Af ) that consisted group A were treated with ibutilide .  Seventy-three ( 52 with AF and 21 with Af ) consisted group B and were treated with intravenous infusion of amiodarone . RESULTS The conversion rate of group A ( ibutilide ) was significantly higher than the conversion rate of group B ( amiodarone ) ( 80 % vs. 57 % , p=0.0054 ) . As regards the kind of arrhythmia separately , for AF there was n't significant difference ( 77 % vs. 69 % , p = ns ) whereas for Af ibutilide was superior to amiodarone ( 87 % vs. 29 % , p=0.003 ) . The conversion rates of ibutilide did n't differ for AF and Af ( 77 % vs. 87 % , p = ns ) . CONCLUSIONS Ibutilide is more effective than amiodarone in converting recent-onset Af to SR whereas both drugs are equally effective in converting recent-onset AF to SR Objective : To evaluate prospect ively the effects of pretreatment with verapamil on the maintenance of sinus rhythm after direct current ( DC ) cardioversion . Design : R and omised , active control , open label , parallel group comparison of verapamil versus digoxin . Setting s : Multicentre study in three teaching and three non-teaching hospitals in Sweden . Patients : 100 consecutive patients with atrial fibrillation ( AF ) of at least four weeks ’ duration and indications for cardioversion were assigned r and omly to two groups , one treated with verapamil ( verapamil group ) and the other with digoxin ( digoxin group ) before cardioversion . Fifty patients were assigned r and omly to each treatment arm . After dropout of four patients from the digoxin group and seven patients from the verapamil group , data obtained from 89 patients were analysed . Interventions : After r and omly assigned pretreatment with either verapamil or digoxin for four weeks , DC cardioversion was performed . If sinus rhythm was restored then verapamil treatment was discontinued . Main outcome measures : The rate of AF recurrence was assessed one , four , eight , and 12 weeks after cardioversion . Results : 6 patients in the verapamil treated group and none in the digoxin treated group reverted to sinus rhythm spontaneously ( p < 0.05 ) . DC cardioversion restored sinus rhythm in 24 of 37 ( 65 % ) patients in the verapamil group and 41 of 46 patients ( 89 % ) in the digoxin group ( p < 0.05 ) . After 12 weeks ’ follow up 28 % ( 13 of 46 ) of digoxin pretreated patients versus 9 % ( four of 43 ) of verapamil pretreated patients remained in sinus rhythm ( p < 0.05 ) . Conclusion : Pretreatment with verapamil alone does not improve maintenance of sinus rhythm after DC cardioversion in patients with AF . The rate of spontaneous cardioversion may be improved by verapamil BACKGROUND Surgical pulmonary veins isolation ( PVI ) is done to restore sinus rhythm ( SR ) in patients with chronic permanent atrial fibrillation ( CPAF ) and mitral valve disease . Here we compare the efficacy of electrical block lines performed with radiofrequency ( RF ) compared with conventional surgery . METHODS R and omized trial of 22 patients with CPAF and indication for mitral valve surgery . Ten patients underwent conventional surgery ( SURG )  and 12 RF .  To prove the efficacy of the blockage lines , epicardial pacemaker wires were placed in the isolated pulmonary veins region ( IPVR ) and right atria ( RA ) . RESULTS There were no differences in the baseline data among the groups . All patients remained in SR during the immediate postoperative period . Block lines were tested in patients who remained in SR during the following days ( eight in SURG and nine in RF ) . The median value of thresholds to conduct the stimulus of IPVR for the RA was 18 mA in SURG and 3 mA in RF ( P < 0.022 ) . Eight SURG patients and seven RF patients ( P < 0.38 ) remained in SR at hospital discharge . Eleven RF patients and one SURG required amiodarone to maintain SR ( P < 0.001 ) . The incidence of recurrent atrial fibrillation ( AF ) in the follow-up was 10.7/100 patients /year in the SURG group versus 73.1/100 patients /year in the RF group ( P = 0.009 ) . CONCLUSIONS PVI by SURG formed more effective block lines than RF . SR at hospital discharge was similar among the groups , but more amiodarone was used in RF . During follow-up , incidence of recurrent AF was higher in the RF group AIMS To compare the effects of sotalol and metoprolol on heart rate , during isotonic ( ITE ) and isometric ( IME ) exercise and daily activities , in digitalized patients with chronic atrial fibrillation . METHODS AND RESULTS The study had a r and omized , single-blinded , crossover design . Twenty-three patients with chronic atrial fibrillation received placebo for 4 weeks , followed by a 4-week period of treatment with sotalol and metoprolol in r and om order . At the end of each period , the patients were assessed with  24-h ECG monitoring , a  cardiopulmonary exercise test  and a  h and grip manoeuvre .  Both agents produced a lower heart rate than placebo at rest and at all levels of isotonic exercise ( P < 0.001 ) without affecting oxygen uptake . Sotalol produced a lower heart rate than metoprolol only at submaximal exercise ( 116 + /- 9 bpm for sotalol vs 125 + /- 11 bpm for metoprolol , P < 0.001 ) . During isometric exercise , sotalol produced a lower maximum heart rate than did metoprolol ( 113 + /- 22 vs 129 + /- 18 bpm , respectively ) . Both agents produced a lower mean heart rate than placebo over 24 h ( P < 0.001 for all ) , while sotalol produced a lower mean heart rate than metoprolol during the daytime ( P < 0.01 ) . CONCLUSION Sotalol is a safe and effective agent for control of heart rate in digitalized patients with atrial fibrillation . Sotalol is superior to metoprolol at submaximal exercise , result ing in better rate control during daily activities Background Catheter ablation ( CA ) is a highly effective therapy for the treatment of paroxysmal atrial fibrillation ( AF ) when compared with antiarrhythmic drug therapy ( ADT ) . No r and omized studies have compared the two strategies in persistent AF . The present r and omized trial aim ed to compare the effectiveness of CA vs. ADT in treating persistent AF . Methods and results Patients with persistent AF were r and omly assigned to CA or ADT ( excluding patients with long-st and ing persistent AF ) . Primary endpoint at 12-month follow-up was defined as any episode of AF or atrial flutter lasting > 24 h that occurred after a 3-month blanking period . Secondary endpoints were any atrial tachyarrhythmia lasting > 30 s , hospitalization , and electrical cardioversion . In total , 146 patients were included ( aged 55 ± 9 years , 77 % male ) . The ADT group received class Ic ( 43.8 % ) or class III drugs ( 56.3 % ) . In an intention-to-treat analysis , 69 of 98 patients ( 70.4 % ) in the CA group and 21 of 48 patients ( 43.7 % ) in the ADT group were free of the primary endpoint ( P = 0.002 ) , implying an absolute risk difference of 26.6 % ( 95 % CI 10.0–43.3 ) in favour of CA . The proportion of patients free of any recurrence ( > 30 s ) was higher in the CA group than in the ADT group ( 60.2 vs. 29.2 % ; P < 0.001 ) and cardioversion was less frequent ( 34.7 vs. 50 % , respectively ; P = 0.018 ) . Conclusion Catheter ablation is superior to medical therapy for the maintenance of sinus rhythm in patients with persistent AF at 12-month follow-up . Clinical Trial Registration Information NCT00863213 ( http:// clinical trials.gov/ct2/show/NCT00863213 ) Background —There has been growing concern that linear ablation is associated with an increased risk of iatrogenic arrhythmias in patients undergoing ablation for atrial fibrillation ( AF ) . Therefore , we compared circumferential pulmonary vein ablation plus left atrial linear ablation ( CPVA+LALA ) with segmental pulmonary vein isolation (PVI)in  patients with paroxysmal AF . Methods and Results —Sixty-six consecutive patients with paroxysmal AF were prospect ively r and omly assigned to receive PVI versus CPVA+LALA ( consisting of encircling lesions around the pulmonary veins ) , a roof line , and a mitral isthmus line with documentation of bidirectional mitral isthmus block . All patients were seen at 1 , 3 , 6 , and every 12 months after ablation , with 14-day continuous ECG monitoring every 6 months . At 16.4±6.3 months after 1 ablation procedure , 19 patients ( 58 % ) remained free of atrial arrhythmias after PVI versus 17 patients ( 51 % ) after CPVA+LALA ( P=0.62 ) . After PVI , 14 patients had recurrent paroxysmal AF , whereas after CPVA+LALA , 8 patients had recurrent AF , 6 had atypical left atrial flutter ( LAFL ) , and 2 had both AF and LAFL ( P=0.32 between PVI versus CPVA+LALA for AF but P=0.002 for LAFL ) . Twenty-eight patients ( 85 % ) remained arrhythmia-free after 1.3±0.5 PVI procedures versus 28 patients ( 85 % ) after 1.4±0.6 CPVA+LALA procedures ( P = NS ) . Fluoroscopy time was longer after CPVA+LALA versus PVI ( 91 versus 73 minutes , P=0.04 ) . Conclusions —As an initial ablation approach in patients with paroxysmal AF  , more LAFL occurred after CPVA+LALA and fluoroscopy times were longer compared with segmental PVI BACKGROUND We conducted a r and omized , controlled trial of circumferential pulmonary-vein ablation for the treatment of chronic atrial fibrillation . METHODS A total of 146 patients with a mean ( + /-SD ) age of 57+/-9 years who had chronic atrial fibrillation were r and omly assigned to receive amiodarone and undergo two cardioversions during the first three months alone ( the control group ) or in combination with circumferential pulmonary-vein ablation . Cardiac rhythm was assessed with daily telephonic transmissions for one year . The left atrial diameter and the severity of symptoms were assessed at 12 months . RESULTS Among the 77 patients assigned to undergo circumferential pulmonary-vein ablation , ablation was repeated because of recurrent atrial fibrillation in 26 percent of patients and atypical atrial flutter in 6 percent . An intention-to-treat analysis showed that 74 percent of patients in the ablation group and 58 percent of those in the control group were free of recurrent atrial fibrillation or flutter without antiarrhythmic-drug therapy at one year ( P=0.05 ) . Among the 69 patients in the control group , 53 ( 77 percent ) crossed over to undergo circumferential pulmonary-vein ablation for recurrent atrial fibrillation by one year and only 3 ( 4 percent ) were in sinus rhythm without antiarrhythmic-drug therapy or ablation . There were significant decreases in the left atrial diameter ( 12+/-11 percent , P<0.001 ) and the symptom severity score ( 59+/-21 percent , P<0.001 ) among patients who remained in sinus rhythm after circumferential pulmonary-vein ablation . Except for atypical atrial flutter , there were no complications attributable to circumferential pulmonary-vein ablation . CONCLUSIONS Sinus rhythm can be maintained long term in the majority of patients with chronic atrial fibrillation by means of circumferential pulmonary-vein ablation independently of the effects of antiarrhythmic-drug therapy , cardioversion , or both . The maintenance of sinus rhythm is associated with a significant decrease in both the severity of symptoms and the left atrial diameter AIMS The aim of this prospect i ve , r and omized study was to determine the efficacy of a serial external electrical cardioversion strategy in maintaining sinus rhythm after 12 months in patients with recurrent persistent atrial fibrillation . METHODS AND RESULTS Ninety patients with persistent atrial fibrillation lasting more than 72 h but less than 1 year were r and omized in a one to one fashion to repetition of up to two electrical cardioversions in the event of relapse of atrial fibrillation detected within 1 month of the previous electrical cardioversion ( Group AGG ) , or to non-treatment of atrial fibrillation relapse ( Group CTL ) .  ECGs  were scheduled at 6 h , 7 days , and 1 month .  Clinical examination and ECGs  were repeated during the 6-month and 12-month follow-up examinations .  Echocardiography  was repeated during the 6-month follow-up examination . Clinical and echocardiographic characteristics were similar in the two groups . All patients were treated with antiarrhythmic drugs before electrical cardioversion and throughout follow-up . After 12 months , sinus rhythm was maintained in 53 % of Group AGG patients and in 29 % of Group CTL patients ( P<0.03 ) . After 6 months , left ventricular ejection fraction had recovered significantly only in Group AGG ( 56.8 + /- 9.0 % at enrollment vs 60.4 + /- 9.4 % at 6 months , P < 0.001 ) . CONCLUSION These results demonstrate that an aggressive policy towards persistent atrial fibrillation by means of repetition of electrical cardioversion after early atrial fibrillation recurrence is useful in maintaining sinus rhythm after 12 months Aims This multicentre , r and omized trial compared three strategies of AF ablation : ablation of complex fractionated electrograms ( CFE ) alone , pulmonary vein isolation ( PVI ) alone , and combined PVI + CFE ablation , using st and ardized automated mapping software . Methods and results Patients with drug-refractory , high-burden paroxysmal ( episodes > 6 h , > 4 in 6 months ) or persistent atrial fibrillation ( AF ) were enrolled at eight centres . Patients ( n = 100 ) were r and omized to one of three arms . For CFE alone ( n = 34 ) , spontaneous/induced AF was mapped using vali date d , automated CFE software and all sites < 120 ms were ablated until AF termination/non-inducibility . For PVI ( n = 32 ) , all four PV antra were isolated and confirmed using a circular catheter . For PVI + CFE ( n = 34 ) , all four PV antra were isolated , followed by AF induction and ablation of all CFE sites until AF termination/non-inducibility . Patients were followed at 3 , 6 , and 12 months with a visit , ECG , 48 h Holter . Atrial fibrillation symptoms were confirmed by loop recording . Repeat procedures were allowed within the first 6 months . The primary endpoint was freedom from AF > 30 s at 1 year . Patients ( age 57 ± 10 years , LA size 42 ± 6 mm ) were 35 % persistent AF . In CFE , ablation terminated AF in 68 % . Only 0.4 PVs per patient were isolated as a result of CFE . In PVI , 94 % had all four PVs successfully isolated . In PVI + CFE , 94 % had all four PVs isolated , 76 % had inducible AF with additional CFE ablation , with 73 % termination of AF . There were significantly more repeat procedures in the CFE arm ( 47 % ) vs. PVI ( 31 % ) or PVI + CFE ( 15 % ) ( P = 0.01 ) . After one procedure , PVI + CFE had a significantly higher freedom from AF ( 74 % ) compared with PVI ( 48 % ) and CFE ( 29 % ) ( P = 0.004 ) . After two procedures , PVI + CFE still had the highest success ( 88 % ) compared with PVI ( 68 % ) and CFE ( 38 % ) ( P = 0.001 ) . Ninety-six percent of these patients were off anti-arrhythmics . Complications were two tamponades , no PV stenosis , and no mortality . Conclusion In high-burden paroxysmal/persistent AF , PVI + CFE has the highest freedom from AF vs. PVI or CFE alone after one or two procedures . Complex fractionated electrogram alone has the lowest one and two procedure success rates with a higher incidence of repeat procedures . Clinical Trials.gov identifier number NCT00367757 OBJECTIVE Radiofrequency or the use of microwave energy in combination with atrial size reduction during open heart surgery have been reported to be effective in up to 75 % in the treatment of permanent atrial fibrillation . However , no data from prospect i ve r and omized trials using microwave energy are available . METHODS Forty-three patients with permanent atrial fibrillation undergoing open-heart surgery were r and omly stratified into treatment group receiving microwave ablation and atrial size reduction ( n=24 ) or control group ( n=19 ) . Patients in either group were treated with amiodarone or sotalol for 3 months if sinus rhythm or any atrioventricular rhythm was successfully restored . Follow-up time points were at 3 , 6 and 12 month after surgery . RESULTS In the treatment group 22 out of 24 patients ( 91,7 % ) were successfully converted to sinus rhythm by using intraoperative microwave ablation therapy whereas only six out of 19 ( 31.5 % ) patients converted to sinus rhythm directly after surgery . At 12-month follow-up there were still a significantly higher percentage of patients in the treatment group free from atrial fibrillation when compared to control ( 80 vs. 33.3 % , P=0.036 ) . CONCLUSION The preliminary data from this first prospect ively r and omized trial indicate that microwave ablation combined with atrial size reduction is a safe and highly efficient treatment in permanent atrial fibrillation Aims Surgical ablation procedure can restore sinus rhythm ( SR ) in patients with atrial fibrillation ( AF ) undergoing cardiac surgery . However , it is not known whether it has any impact on long-term clinical outcomes . Methods and results This multicentre study r and omized 224 patients with AF scheduled for valve and /or coronary surgery : group A  ( left atrial surgical ablation , n = 117 ) vs. group B  ( no ablation , n = 107 ) . The primary efficacy outcome was the SR presence ( without any AF episode ) during a 24 h electrocardiogram ( ECG )  after 1 year . The primary safety outcome was the combined endpoint of death/myocardial infa rct ion/stroke/renal failure at 30 days . A Holter-ECG after 1 year revealed SR in 60.2 % of group A patients vs. 35.5 % in group B ( P = 0.002 ) . The combined safety endpoint at 30 days occurred in 10.3 % ( group A ) vs. 14.7 % ( group B , P = 0.411 ) . All-cause 1-year mortality was 16.2 % ( A ) vs. 17.4 % ( B , P = 0.800 ) . Stroke occurred in 2.7 % ( A ) vs. 4.3 % ( B ) patients ( P = 0.319 ) . No difference ( A vs. B ) in SR was found among patients with paroxysmal ( 61.9 vs. 58.3 % ) or persistent ( 72 vs. 50 % ) AF , but ablation significantly increased SR prevalence in patients with longst and ing persistent AF ( 53.2 vs. 13.9 % , P < 0.001 ) . Conclusion Surgical ablation improves the likelihood of SR presence post-operatively without increasing peri-operative complications . However , the higher prevalence of SR did not translate to improved clinical outcomes at 1 year . Further follow-ups ( e.g. 5-year ) are warranted to show any potential clinical benefit which might occur later Background — Data on the comparative value of the circumferential pulmonary vein and the segmental pulmonary vein ablation for interventional treatment of atrial fibrillation are limited . We hypothesized that the circumferential pulmonary vein ablation approach was superior to the segmental pulmonary vein ablation approach . Methods and Results —One hundred patients with highly symptomatic atrial fibrillation were r and omly assigned to undergo either circumferential ( n=50 ) or segmental pulmonary vein ablation ( n=50 ) . Freedom from atrial tachyarrhythmias in a 7-day Holter monitoring at 6 months was the primary end point . Secondary end points were freedom of arrhythmia-related symptoms and a composite of pericardial tamponade , thromboembolic complications , and pulmonary vein stenosis ( safety end point ) . On the basis of the results of the 7-day Holter monitoring at 6 months , 21 patients ( 42 % ) after circumferential pulmonary vein ablation and 33 patients ( 66 % ) after segmental pulmonary vein ablation ( P=0.02 ) were free of atrial tachyarrhythmia episodes . During the 6-month follow-up period , 27 patients ( 54 % ) after circumferential pulmonary vein ablation and 41 patients ( 82 % ) after segmental pulmonary vein ablation remained free of arrhythmia-related symptoms ( P<0.01 ) . No significant difference was found in the safety end point ( 6 versus 7 events ; P=0.77 ) in the circumferential versus segmental pulmonary vein ablation group , respectively . Conclusions —This study demonstrates no superiority of the circumferential pulmonary vein ablation over segmental pulmonary vein ablation for treatment of atrial fibrillation in terms of efficacy and safety AIMS Catheter ablation and surgical Maze procedure are effective in treating atrial fibrillation ( AF ) patients . However , there is no study that compares the effect of circumferential pulmonary vein isolation ( CPVI ) combined with substrate ablation after valvular surgery and the concomitant Maze procedure for the treatment of AF in patients with rheumatic heart disease ( RHD ) . The aim of this study was to compare the effectiveness of CPVI combined with substrate modification and surgical Maze procedure using Saline-Irrigated Cooled-tip Radiofrequency Ablation ( SICTRA ) system for the treatment of long-lasting persistent AF in patients with RHD . METHODS AND RESULTS Between January 2006 and June 2008 , 99 patients with long-lasting persistent AF and RHD were r and omly assigned to undergo valvular operation and CPVI combined with substrate modification 6 months after the surgery ( Group A , 49 patients ) or valvualr operation and concomitant Maze procedure ( Group B , 50 patients ) . The mean follow-up periods were 15 ± 5 and 20 ± 8 months in Groups A and B , respectively . After one procedure , Group B had a significantly higher freedom from artial arrhythmias compared with Group A ( 82 % in Group B vs. 55.2 % in Group A , P < 0.001 ) . Fifteen patients in Group A underwent a redo procedure . Six patients in Group B underwent  catheter  ablation and four were treated successfully . The cumulative rates of sinus rhythm were 71 % in Group A and 88 % in Group B ( P < 0.001 ) . CONCLUSION The concomitant Cox Maze procedure using SICTRA is more effective than subsequent CPVI combined with substrate modification in treating patients with long-lasting persistent AF and RHD UNLABELLED This r and omized study compared the efficacy and safety of amiodarone , propafenone and sotalol in the prevention of atrial fibrillation . METHODS The population consisted of 214 consecutive patients ( mean age 64 + /- 8 years , 106 men ) with recurrent symptomatic atrial fibrillation . After restoration of sinus rhythm , patients were r and omized to amiodarone ( 200 mg/day ) , propafenone ( 450 mg/day ) or sotalol ( 320 + /- 20 mg/day ) . Follow-up evaluations were conducted at 1 , 2 , 4 and 6 months , and at 3-month intervals thereafter . The proportion of patients developing recurrent atrial fibrillation and /or experiencing unacceptable adverse effects was measured in the three groups by the Kaplan-Meier method . RESULTS Recurrent atrial fibrillation occurred in 25 of the 75 patients treated with amiodarone compared to 51 of the 75 patients treated with sotalol and 24 of the 64 patients treated with propafenone . Fourteen patients treated with amiodarone , five with sotalol , and one with propafenone experienced adverse effects while in sinus rhythm , necessitating discontinuation of treatment ( P < 0.001 for amiodarone and propafenone vs sotalol ) . The difference between amiodarone and propafenone was statistically nonsignificant when all events were included in the analysis . However , if the analysis was limited to recurrent atrial fibrillation events , amiodarone was more effective than propafenone ( P < 0.05 ) . CONCLUSIONS Amiodarone and propafenone were superior to sotalol in maintaining long-term normal sinus rhythm in patients with atrial fibrillation .  Amiodarone tended to be superior to propafenone , though its long-term efficacy was limited by adverse side effects OBJECTIVES This study sought to determine whether ablation of complex fractionated atrial electrograms ( CFAEs ) after antral pulmonary vein isolation ( APVI ) further improves the clinical outcome of APVI in patients with long-lasting persistent atrial fibrillation ( AF ) . BACKGROUND Ablation of CFAEs has been reported to eliminate persistent AF . However , residual pulmonary vein arrhythmogenicity is a common mechanism of recurrence . METHODS In this r and omized study , 119 consecutive patients ( mean age 60 + /- 9 years ) with long-lasting persistent AF underwent APVI with an irrigated-tip radiofrequency ablation catheter . Antral pulmonary vein isolation result ed in termination of AF in 19 of 119 patients ( Group A , 16 % ) . The remaining 100 patients who still were in AF were r and omized to no further ablation and underwent cardioversion ( Group B , n = 50 ) or to ablation of CFAEs in the left atrium or coronary sinus for up to 2 additional hours of procedure duration ( Group C , n = 50 ) . RESULTS Atrial fibrillation terminated during ablation of CFAEs in 9 of 50 patients ( 18 % ) in Group C. At 10 + /- 3 months after a single ablation procedure , 18 of 50 ( 36 % ) in Group B and 17 of 50 ( 34 % ) in Group C were in sinus rhythm without antiarrhythmic drugs ( p = 0.84 ) . In Group A , 15 of 19 patients ( 79 % ) were in sinus rhythm . A repeat ablation procedure was performed in 34 of 100 r and omized patients ( for AF in 30 and atrial flutter in 4 ) . At 9 + /- 4 months after the final procedure , 34 of 50 ( 68 % ) in Group B and 30 of 50 ( 60 % ) in Group C were in sinus rhythm without antiarrhythmic drugs ( p = 0.40 ) . CONCLUSIONS Up to 2 h of additional ablation of CFAEs after APVI does not appear to improve clinical outcomes in patients with long-lasting persistent AF BACKGROUND Detailed analysis of signal-averaged P waves ( SAPW ) can provide insights into atrial electrophysiology . Abbreviated dosing of verapamil prior to cardioversion improves outcome at 1 week postcardioversion . The mechanism by which verapamil manifests benefit is uncertain . We hypothesized the SAPW would reflect any change in atrial electrophysiologic substrate afforded by verapamil when compared with controls . METHODS We investigated 23 patients attending external cardioversion of persistent atrial fibrillation ( AF ) ( 6 female ; mean age 68 years ) . Patients were r and omized to verapamil 240 mg daily in three divided doses 3 days before cardioversion and 1 week after , or usual medication .  SAPW recordings were performed during sinus rhythm ( SR ) immediately after cardioversion , at 24 hours and 1 week . RESULTS The groups were comparable in terms of age , gender , left atrial size , and duration of AF . Eight of nine patients prescribed verapamil maintained SR at 1 week postcardioversion compared with 6 of 14 controls ( P = 0.027 ) . SAPW spectral analysis delivered higher energy for patients prescribed verapamil ( median ( IQ range ) ) ; 40.8 ( 33.4 - 95.1 ) versus 25.7 ( 19.0 - 38.0 ) for energy within 20 - 150 Hz , P20 ( microV(2)x s ; P = 0.03 ) . There was no difference in P-wave duration ( PWD ) or root mean square of the terminal 30 ms between the two groups . Early reinitiation occurred in patients with significantly lower P-wave energy 19.6 ( 12.9 - 24.6 ) versus 39.9 ( 24.0 - 47.0 ) ( P = 0.017 ) . CONCLUSIONS Verapamil 240 mg daily for 3 days prior to cardioversion and 1 week after reduces early recurrence of AF . The SAPW observations indicate change in atrial electrophysiologic substrate might be responsible for benefit afforded by verapamil BACKGROUND The deployment of an ablation line connecting the left inferior PV to the mitral annulus ( mitral isthmus line [ MIL ] ) enhances the efficacy of pulmonary vein disconnection ( PVD ) in preventing atrial fibrillation ( AF ) recurrences . OBJECTIVES To investigate the long-term effect of the additional linear lesion in a prospect i ve r and omized study . METHODS One hundred and eighty-seven patients ( 37 females , mean age : 55 + /- 11 years ) with paroxysmal ( 126 ) or persistent ( 61 patients ) AF , were prospect ively r and omized into two groups : PVD ( group A , 92 patients ) or PVD combined with MIL ( group B , 95 patients ) , performed by means of an irrigated-tip ablation catheter . RESULTS Successful disconnection of all PVs was achieved in all patients . A bidirectional block ( BB ) along the left atrial isthmus was obtained in 72 of 95 ( 76 % ) patients in group B , most of whom required additional RF pulses from within the distal CS . A transient ischemic attack occurred in 1 patient of group A , and a cardiac tamponade occurred in 1 patient of group B. At 1 year , 53 + /- 5 % ( group A ) and 71 + /- 5 % ( group B ) remained arrhythmia free ( P = 0.01 ) ; subgroup analysis highlights a higher improvement among patients with persistent AF ( 74 + /- 9 % vs 36 + /- 9 % ; P < 0.01 ) than what was observed in paroxysmal AF ( 76 + /- 6 % vs 62 + /- 6 % ; P < 0.05 ) ; antiarrhythmic drugs were continued in 56 % and 50 % , respectively , in groups A and B ( P = ns ) . CONCLUSIONS The addition of mitral isthmus line to the PV disconnection allows a significant improvement of sinus rhythm maintenance rate , particularly in patients with persistent AF , without the risk for major complications AIM To compare ventricular rate responsive ( VVIR ) pacing with dual chamber rate responsive ( DDDR ) pacing and antiarrhythmic drugs for the treatment of patients with persistent atrial fibrillation after atrioventricular node ablation . METHODS One hundred two patients with persistent atrial fibrillation eligible for the atrioventricular node ablation were r and omly assigned to the therapy with either VVIR pacemaker ( n=52 ) or DDDR pacemaker and antiarrhythmic drugs ( n=50 ) . After ablation , patients in both pacing groups were assigned to take anticoagulant therapy . The primary end point was stroke or death from cardiovascular causes . RESULTS After a mean follow-up of 26.6+/-9.5 months , there was no difference in the stroke or death rates between patients with VVIR pacing ( 6 or 5.2 % per year ) and those with DDDR pacing and antiarrhythmic drugs ( 6 or 5.9 % per year , P=0.930 ) . The observed rates of death from all causes , hospitalization for heart failure , and myocardial ischemia were similar in the two patient groups . There was a significantly lower rate of development of permanent atrial fibrillation in patients with DDDR pacing and antiarrhythmic drugs , with a reduction in absolute risk by 56 % and relative risk by 64 % ( 32 % vs 88 % ; P<0.001 ) . CONCLUSION With respect to cardiovascular death and morbidity , VVIR pacing is not inferior to DDDR pacing and antiarrhythmic drugs for the treatment of patients with persistent atrial fibrillation after atrioventricular node ablation and may be considered as an appropriate therapy for such patients Objective Cardioversion of atrial fibrillation by means of a monophasic transthoracic shock is facilitated by pretreatment with ibutilide . The aim of this study was to r and omly and prospect ively compare the energy requirements of transthoracic biphasic cardioversion of atrial fibrillation with and without ibutilide pretreatment . Methods Fifty patients were enrolled and r and omized into two groups : immediate cardioversion with biphasic shock ( group 1 ) or ibutilide pretreatment followed by cardioversion with biphasic shock ( group 2 ) . In group 2 , ibutilide was administered intravenously in 10 min at a dose of 0.01 mg/kg . A pause of 10 min was observed before the patients underwent cardioversion . Results All patients of both groups were successfully cardioverted ( 100 % ) . Energy and number of shocks were significantly lower in group 2 than in group 1 ( P < 0.02 ) . Eleven of 25 patients ( 44 % ) in group 1 and 15 of 23 patients ( 65 % ) in group 2 were cardioverted at the first attempt with 50 J. The number of patients cardioverted at the first attempt with 50 J was significantly higher in group 2 than in group 1 ( P = 0.018 ) . Conclusions Although not essential for a successful outcome , pretreatment with ibutilide can lower energy requirements in transthoracic biphasic cardioversion INTRODUCTION Many relapses of atrial fibrillation ( AF ) occur , especially during the first week(s ) after electrical cardioversion ( ECV ) . The aim of the present study was to compare in a r and omized design the efficacy of verapamil ( intracellular calcium lowering ) versus digoxin ( calcium increasing ) for maintenance of sinus rhythm after ECV . METHODS AND RESULTS Ninety-seven patients with persistent AF were r and omized to verapamil ( n = 49 ) or digoxin ( n = 48 ) for 1 month before and 1 month after ECV . The first month after ECV , patients recorded heart rhythm using daily transtelephonic monitoring . No additional antiarrhythmic drugs were given . Of the 97 patients , 43 patients ( 20 verapamil ) underwent ECV per protocol . Median previous AF duration was 18 and 26 days for verapamil and digoxin , respectively . There were no differences in atrial dimensions and underlying heart disease between the two groups . The success rate of ECV  was 75 % versus 83 % ( P = NS ) . After 1 month , 47 % versus 53 % ( P = NS ) had recurrence of AF . Median time to recurrence was 5 days ( range 0 to 26 ) versus 8 days ( range 2 to 28 ) ( P = NS ) , respectively . CONCLUSION St and -alone intracellular calcium lowering by verapamil around ECV does not enhance cardioversion outcome Objectives : To compare the clinical efficacy of intravenous diltiazem , digoxin , and amiodarone for acute ventricular rate ( VR ) control in patients with acute symptomatic atrial fibrillation ( AF ) necessitating hospitalization . Design : R and omized control trial . Setting : Acute emergency medical admission unit in a regional teaching hospital in Hong Kong . Patients : One hundred fifty adult patients with acute AF and rapid VR ( > 120 bpm ) . Interventions : Patients were r and omly assigned in 1:1:1 ratio to receive intravenous diltiazem , digoxin , or amiodarone for VR control . Measurements and Main Results : The primary end point was sustained VR control ( < 90 bpm ) within 24 hours ; the secondary end points included AF symptom improvement and length of hospitalization . At 24 hours , VR control was achieved in 119 of 150 patients ( 79 % ) . The time to VR control was significantly shorter among patients in the diltiazem group ( log-rank test , p < 0.0001 ) with the percentage of patients who achieved VR control being higher in the diltiazem group ( 90 % ) than the digoxin group ( 74 % ) and the amiodarone group ( 74 % ) . The median time to VR control was significantly shorter in the diltiazem group ( 3 hours , 1–21 hours ) compared with the digoxin ( 6 hours , 3–15 hours , p < 0.001 ) and amiodarone groups ( 7 hours , 1–18 hours , p = 0.003 ) . Furthermore , patients in the diltiazem group persistently had the lowest mean VR after the first hour of drug administration compared with the other two groups ( p < 0.05 ) . The diltiazem group had the largest reduction in AF symptom frequency score and severity score ( p < 0.0001 ) . In addition , length of hospital stay was significantly shorter in the diltiazem group ( 3.9 ± 1.6 days ) compared with digoxin ( 4.7 ± 2.1 days , p = 0.023 ) and amiodarone groups ( 4.7 ± 2.2 days , p = 0.038 ) . Conclusions : As compared with digoxin and amiodarone , intravenous diltiazem was safe and effective in achieving VR control to improve symptoms and to reduce hospital stay in patients with acute AF Purpose We tested the hypothesis that electroanatomic pulmonary vein ( PV ) antra encircling for the PV isolation will improve the outcome in treatment of paroxysmal atrial fibrillation ( PAF ) , compared with segmental PV isolation . Methods Fifty-four patients underwent segmental PV isolation ( group 1 ) and 56 patients circumferential PV isolation ( group 2 ) for symptomatic PAF in a r and omized study . Results Following single ablation procedure , at the 48 ± 8 month follow-up , 30 ( 56 % ) and 32 ( 57 % ) patients in groups 1 and 2 remained free of arrhythmia ( P = 0.41 ) . After repeat ablation , 43 ( 80 % ) and 45 ( 80 % ) patients in groups 1 and 2 were free of arrhythmia without antiarrhythmic drugs ( AADs ) ; 48 ( 89 % ) and 51 ( 91 % ) patients in groups 1 and 2 did not have arrhythmia recurrences without or with AADs . Conclusion This study demonstrates no advantage in long-term arrhythmia-free clinical outcome after circumferential PV isolation in patients with frequent PAF AIMS Permanent atrial fibrillation develops in many patients after ablation and pacing therapy .  We compared a strategy that initially allowed patients to remain in atrial fibrillation with a strategy that initially attempted to restore and maintain sinus rhythm . METHODS AND RESULTS In this multicentre r and omized controlled trial , 68 patients affected by severely symptomatic paroxysmal atrial fibrillation were assigned , after successful atrioventricular junction ablation and pacing treatment  , to antiarrhythmic drug therapy with amiodarone , propafenone , flecainide or sotalol and were compared with 69 patients assigned , after successful AV junction ablation and pacing treatment , to no antiarrhythmic drug therapy . The patients were followed-up for 12 to 24 months ( mean 16+/-4 ) . The drug arm patients had a 57 % reduction in the risk of developing permanent atrial fibrillation ( 21 % vs 37 % , P=0.02 ) . Evaluation after 12 months revealed similar quality of life scores and echocardiographic parameters in the two groups , but the drug arm patients had more episodes of heart failure and hospitalizations ( P=0.05 ) . The outcome was similar between the 40 patients who developed permanent atrial fibrillation and the 97 who did not . CONCLUSION Conventional antiarrhythmic therapy reduces the risk of development of permanent atrial fibrillation after ablation and pacing therapy . The present data do not support the concept that the development of permanent atrial fibrillation is related to an adverse outcome when a perfect control of heart rate is obtained by ablation and pacing AIMS We conducted a multi-centre , prospect i ve , controlled , r and omized trial to investigate the adjunctive role of ablation therapy to antiarrhythmic drug therapy in preventing  atrial fibrillation ( AF )  relapses in patients with paroxysmal or persistent AF in whom antiarrhythmic drug therapy had already failed . METHODS AND RESULTS One hundred and thirty seven patients were r and omized to ablation and antiarrhythmic drug therapy ( ablation group ) or antiarrhythmic drug therapy alone ( control group ) . In the ablation group , patients underwent cavo-tricuspid and left inferior pulmonary vein (PV)-mitral isthmus ablation plus circumferential PV ablation . The primary end-point of the study was the absence of any recurrence of atrial arrhythmia lasting > 30 s in the 1-year follow-up period , after 1-month blanking period . Three ( 4.4 % ) major complications were related to ablation : one patient had a stroke during left atrium ablation , another suffered transient phrenic paralysis , and the third had a pericardial effusion which required pericardiocentesis . After 12 months of follow-up , 63/69 ( 91.3 % ) control group patients had at least one AF recurrence , whereas 30/68 ( 44.1 % ) ( P<0.001 ) ablation group patients had atrial arrhythmia recurrence ( four patients had atrial flutter , 26 patients AF ) . CONCLUSION Ablation therapy combined with antiarrhythmic drug therapy is superior to antiarrhythmic drug therapy alone in preventing atrial arrhythmia recurrences in patients with paroxysmal or persistent AF in whom antiarrhythmic drug therapy has already failed Background — The single-procedure efficacy of pulmonary vein isolation ( PVI ) is less than optimal in patients with persistent atrial fibrillation ( AF ) . Adjunctive techniques have been developed to enhance single-procedure efficacy in these patients . We conducted a study to compare 3 ablation strategies in patients with persistent AF . Methods and Results — Subjects were r and omized as follows : arm 1 , PVI + ablation of non-PV triggers identified using a stimulation protocol ( st and ard approach ) ; arm 2 , st and ard approach + empirical ablation at common non-PV AF trigger sites ( mitral annulus , fossa ovalis , eustachian ridge , crista terminalis , and superior vena cava ) ; or arm 3 , st and ard approach + ablation of left atrial complex fractionated electrogram sites . Patients were seen at 6 weeks , 6 months , and 1 year ; transtelephonic monitoring was performed at each visit . Antiarrhythmic drugs were discontinued at 3 to 6 months . The primary study end point was freedom from atrial arrhythmias off antiarrhythmic drugs at 1 year after a single-ablation procedure . A total of 156 patients ( aged 59±9 years ; 136 males ; AF duration , 47±50 months ) participated ( arm 1 , 55 patients ; arm 2 , 50 patients ; arm 3 , 51 patients ) . Procedural outcomes ( procedure , fluoroscopy , and PVI times ) were comparable between the 3 arms . More lesions were required to target non-PV trigger sites than a complex fractionated electrogram ( 33±9 versus 22±9 ; P<0.001 ) . The primary end point was achieved in 71 patients and was worse in arm 3 ( 29 % ) compared with arm 1 ( 49 % ; P=0.04 ) and arm 2 ( 58 % ; P=0.004 ) . Conclusions — These data suggest that additional substrate modification beyond PVI does not improve single-procedure efficacy in patients with persistent AF . Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT00379301 Abstract Purpose : To assess the effects of amiodarone and diltiazem on atrial fibrillation ( AF ) induced atrial electrical remodeling and their clinical implication s. Methods : Persistent AF patients were r and omly assigned to three treatment groups over a period from 6 weeks before to 6 weeks after internal cardioversion : group A ( 35 patients , oral diltiazem ) , group B ( 34 patients , oral amiodarone ) and group C ( 37 patients , no antiarrhythmic drugs ) . Several electrophysiological parameters were assessed 5 min and 24 h after cardioversion . Results : Compared with controls , group B patients had significantly higher conversion rates ( 83 % vs. 100 % , p = 0.041 ) and a higher probability to maintain sinus rhythm ( p = 0.037 ) . Patients of group B had longer fibrillatory cycle length intervals than patients of group A and C ( 180 ± 18 ms vs. 161 ± 17 ms vs. 164 ± 19 ms , p = 0.001 ) and longer atrial effective refractory periods ( 211 ± 22 ms vs. 198 ± 16 ms vs. 194 ± 17 ms , p = 0.003 ) as assessed 5 min after conversion . Post-conversion density of supraventricular ectopics was significantly lower in group B compared to groups A and C ( p = 0.001 ) . Conclusions : Oral amiodarone  increases conversion rates , prolongs fibrillatory cycle length and atrial effective refractory period and preserves sinus rhythm after cardioversion in persistent AF patients by suppressing the atrial ectopics that trigger AF Atrial fibrillation ( AF ) is a very common cardiac arrhythmia with an increased mortality in patients with heart failure . Whether the best therapeutic approach to these patients is to restore sinus rhythm or to adequately control the ventricular rate is still controversial . The aim of this study was to compare both strategies in patients with AF and nonischemic heart failure . One hundred and fifty-four patients with AF duration greater than 48 hours and nonischemic left ventricular dysfunction were r and omized either to a rhythm ( n = 84 ) or rate ( n = 74 ) control group . The composite end points of the study were embolism , death , and exercise capacity .  The average age of the patients was 61 + /- 10 years in the rhythm control group and 58 + /- 12 years in the rate control group ( P = NS ) . The average follow-up period was 35 + /- 21 months in the rhythm control group and 37 + /- 19 months in the rate control group ( P = NS ) . In the first year of the study , exercise capacity and left ventricular ejection fraction ( LVEF ) were improved in the rhythm control group compared to the exercise capacity and LVEF of the rate control group ( P < 0.0001 and P = 0.0005 , respectively ) . There were no statistically significant differences in the embolic event rate between the two groups ( P = NS ) . The mortality rate , especially for death due to pump failure , was significantly higher in the rate control group at the end of the study ( P < 0.0001 ) . Restoring and maintaining sinus rhythm had a beneficial effect on mortality and exercise capacity in patients with nonischemic heart failure and AF INTRODUCTION Circumferential pulmonary vein antral isolation ( PVAI ) and atrial complex fractionated electrograms ( CFEs ) are both ablative techniques for the treatment of paroxysmal atrial fibrillation ( PAF ) . However , data on the comparative value of these 2 ablation strategies are very limited . METHODS AND RESULTS We r and omized 118 patients with drug-refractory PAF to receive  PVAI ablation ( n = 60 ) or CFE ablation ( n = 58 ) . For CFE group , spontaneous/induced AF was mapped using vali date d , automated software to guide ablation until all CFE areas were eliminated . For PVAI group , all 4 pulmonary vein antra were electrically isolated as confirmed by circular mapping catheter . Patients with spontaneous/inducible AF after the initial ablation procedure were crossed over to the other arms . After initial ablation procedure , AF persisted/inducible in 24/59 patients ( 41 % ) , and 34/58 patients ( 59 % ) assigned to PVAI and CFE ablation , respectively ( P = 0.05 ) . Then 58 patients underwent PVAI + CFE ablation . After 22.6 ± 6.4 months , PVAI ablation group was more likely than CFE ablation group to achieve control of any AF/atrial tachycardia ( AT ) off drugs ( 43/60 , 72 % vs 33/58 , 57 % , P = 0.075 ) and lower recurrence rate of AT ( 11.9 % vs 34.5 % , P = 0.004 ) . Patients who received CFE ablation alone ( 38 % ) had significantly lower overall success rate to achieve control of AF/AT off drugs compared with patients who received PVAI ablation ( 77 % , P = 0.002 ) alone or PVAI + CFE ablation ( 69 % , P = 0.008 ) due to higher recurrence rate of AT ( 50 % vs 6 % vs 13 % , P < 0.01 ) . CONCLUSIONS CFE ablation in PAF patients was associated with higher occurrence rate of postprocedure AT compared with PVAI ablation , whereby making it less likely to be a sole ablation strategy for PAF patients Objective To compare the efficacy of electrical versus pharmacological cardioversion following prosthetic cardiac valve replacement in patients with permanent atrial fibrillation ( AF ) . Methods Patients with permanent AF who had undergone prosthetic cardiac valve replacement , who had a cardiothoracic ratio ≤0.5 and a left atrial diameter ≤50 mm for ≥6 months after surgery were r and omly divided to receive either electrical or pharmacological cardioversion . Patients in the electrical cardioversion group were given direct-current synchronized electrical defibrillation under general anaesthesia . Patients in the pharmacological cardioversion group were given oral combination therapy with amiodarone , captopril and simvastatin for 3 months . Results A total of 115 patients received either electrical cardioversion ( n = 59 ) or pharmacological cardioversion ( n = 56 ) ; reversion to sinus rhythm occurred in 98.3 % and 26.8 % , respectively . Recurrence rates were similar in the two groups ( 3.4 % and 6.7 % for electrical and pharmacological cardioversion , respectively ) . No deaths or severe complications were reported . Conclusion Electrical cardioversion has a favourable safety profile and appears to be a more effective method than pharmacological cardioversion for the treatment of permanent AF after cardiac valve replacement , once the heart has returned close to its normal size OBJECTIVES This study compared a biphasic waveform with a conventional monophasic waveform for cardioversion of atrial fibrillation ( AF ) . BACKGROUND Biphasic shock waveforms have been demonstrated to be superior to monophasic shocks for termination of ventricular fibrillation , but data regarding biphasic shocks for conversion of AF are still emerging . METHODS In an international , multicenter , r and omized , double-blind clinical trial , we compared the effectiveness of damped sine wave monophasic versus impedance-compensated truncated exponential biphasic shocks for the cardioversion of AF . Patients received up to five shocks , as necessary for conversion : 100 J , 150 J , 200 J , a fourth shock at maximum output for the initial waveform ( 200 J biphasic , 360 J monophasic ) and a final cross-over shock at maximum output of the alternate waveform . RESULTS Analysis included 107 monophasic and 96 biphasic patients . The success rate was higher for biphasic than for monophasic shocks at each of the three shared energy levels ( 100 J : 60 % vs. 22 % , p < 0.0001 ; 150 J : 77 % vs. 44 % , p < 0.0001 ; 200 J : 90 % vs. 53 % , p < 0.0001 ) . Through four shocks , at a maximum of 200 J , biphasic performance was similar to monophasic performance at 360 J ( 91 % vs. 85 % , p = 0.29 ) . Biphasic patients required fewer shocks ( 1.7 + /- 1.0 vs. 2.8 + /- 1.2 , p < 0.0001 ) and lower total energy delivered ( 217 + /- 176 J vs. 548 + /- 331 J , p < 0.0001 ) . The biphasic shock waveform was also associated with a lower frequency of dermal injury ( 17 % vs. 41 % , p < 0.0001 ) . CONCLUSIONS For the cardioversion of AF , a biphasic shock waveform has greater efficacy , requires fewer shocks and lower delivered energy , and results in less dermal injury than a monophasic shock waveform Prior studies have suggested that intravenous diltiazem reduces the probability of spontaneous conversion of atrial fibrillation ( AF )  to sinus rhythm in the electrophysiology laboratory and in patients with postoperative AF . Whether diltiazem exerts the same effect in patients presenting to the emergency department ( ED ) with spontaneous AF is unclear . Fifty patients presenting to the ED with new-onset or paroxysmal AF and a rapid ventricular rate ( > 100 beats per minute ) were r and omly assigned to receive intravenous diltiazem or esmolol during the first 24 hours of presentation . Conversion to sinus rhythm occurred in 10 patients ( 42 % ) in the diltiazem group compared with 10 patients ( 39 % ) in the esmolol group ( P = 1.0 ) . Diltiazem does not decrease the likelihood of spontaneous conversion of AF to sinus rhythm in the ED setting BACKGROUND Chronic right ventricular pacing has been reported to promote cardiac dyssynchrony . The PAVE trial prospect ively compared chronic biventricular pacing to right ventricular pacing in patients undergoing ablation of the AV node for management of atrial fibrillation with rapid ventricular rates . METHODS AND RESULTS One hundred and eighty-four patients requiring AV node ablation were r and omized to receive a biventricular pacing system ( n = 103 ) or a right ventricular pacing system ( n = 81 ) . The study endpoints were change in the 6-minute hallway walk test , quality of life , and left ventricular ejection fraction .  Patient characteristics were similar ( 64 % male ; age : 69 + /- 10 years , ejection fraction : 0.46 + /- 0.16 ; 83 % , NYHA Class II or III ) . At 6 months postablation , patients treated with cardiac resynchronization had a significant improvement in 6-minute walk distance , ( 31 % ) above baseline ( 82.9 + /- 94.7 m ) , compared to patients receiving right ventricular pacing , ( 24 % ) above baseline ( 61.2 + /- 90.0 m ) ( P = 0.04 ) . There were no significant differences in the quality -of-life parameters . At 6 months postablation , the ejection fraction in the biventricular group ( 0.46 + /- 0.13 ) was significantly greater in comparison to patients receiving right ventricular pacing ( 0.41 + /- 0.13 , P = 0.03 ) . Patients with an ejection fraction < or=45 % or with NYHA Class II/III symptoms receiving a biventricular pacemaker appear to have a greater improvement in 6-minute walk distance compared to patients with normal systolic function or Class I symptoms . CONCLUSION For patients undergoing AV node ablation for atrial fibrillation , biventricular pacing provides a significant improvement in the 6-minute hallway walk test and ejection fraction compared to right ventricular pacing . These beneficial effects of cardiac resynchronization appear to be greater in patients with impaired systolic function or with symptomatic heart failure BACKGROUND The energy requirement for internal ventricular defibrillation is reduced by reversal of shock polarity . The influence of shock polarity on the efficacy of transthoracic atrial defibrillation is unknown . METHODS This prospect i ve , r and omized study enrolled 110 consecutive patients who were referred for elective cardioversion of persistent atrial fibrillation ( AF ) .  The electrodes were placed in the anteroposterior position . The patients were r and omized to receive either st and ard ( anterior pad = cathode ) or reversed polarity ( anterior pad = anode ) shocks with a damped sinusoidal monophasic waveform . A step-up protocol was used to estimate the cardioversion threshold . The initial shock energy was 50 J , with subsequent increments to 100 , 200 , 300 , and 360 J in the event of cardioversion failure . RESULTS Sixty-four percent of the patient population were men , with a mean age of 66 + /- 13 years and a mean duration of AF of 242 + /- 556 days . The overall success rates of cardioversion were 84 % for st and ard polarity and 78 % for reversed polarity ( P not significant ) . Among the patients who were successfully cardioverted , the mean atrial defibrillation threshold was 198 + /- 103 J for st and ard polarity and 212 + /- 107 J for reversed polarity ( P not significant ) . CONCLUSIONS Reversal of shock polarity does not improve transthoracic cardioversion efficacy with a st and ard damped sinusoidal monophasic waveform . Alternate strategies should be considered for patients who fail external cardioversion , such as adjunctive pharmacologic treatment , use of a biphasic shock waveform , or internal cardioversion CONTEXT Although left atrial radiofrequency ablation ( RFA ) is increasingly used for the treatment of chronic atrial fibrillation during mitral valve surgery , its efficacy to restore sinus rhythm and any result ing benefits have not been examined in the context of an adequately powered r and omized trial . OBJECTIVE To determine whether intraoperative RFA of the left atrium increases the long-term restoration of sinus rhythm and improves exercise capacity . DESIGN , SETTING , AND PATIENTS R and omized , double-blind trial performed in a single UK tertiary referral center with enrollment between December 2001 and November 2003 . A total of 101 patients referred for mitral valve surgery with at least 6 months ' history of uninterrupted atrial fibrillation were assessed for eligibility ; 97 were enrolled . Patients were followed up for 12 months . INTERVENTION Patients were r and omly assigned to undergo mitral valve surgery and RFA of the left atrium ( n = 49 ) or mitral valve surgery alone ( controls ; n = 48 ) . MAIN OUTCOME MEASURES The primary outcome measure was presence of sinus rhythm at 12 months ; secondary measures were patient functional status and exercise capacity ( assessed by shuttle-walk test ) , left atrial contractility , and left atrial and left ventricular dimension and function and plasma levels of B-type natriuretic peptide . RESULTS At 12 months , sinus rhythm was present in 20 ( 44.4 % ) of 45 RFA patients and in 2 ( 4.5 % ) of 44 controls ( rate ratio , 9.8 ; 95 % CI , 2.4 - 86.3 ; P<.001 ) . Restoration of sinus rhythm in the RFA group was accompanied by a greater improvement in mean ( SD ) shuttle-walk distance compared with controls ( + 94 [ 102 ] m vs + 48 [ 82 ] m ; P = .003 ) and a greater reduction in the plasma level of B-type natriuretic peptide ( -104 [ 87 ] fmol/mL vs -51 [ 82 ] fmol/mL ; P = .03 ) . Patients r and omized to receive RFA had similar rates of postoperative complications and deaths as control patients . CONCLUSIONS Radiofrequency ablation of the left atrium during mitral valve surgery for continuous atrial fibrillation significantly increases the rate of sinus rhythm restoration 1 year postoperatively , improving patient exercise capacity . On the basis of its efficacy and safety , routine use of RFA of the left atrium during mitral valve surgery may be justified . TRIAL REGISTRATION Clinical Trials.gov Identifier : NCT00238706 Ninety patients who underwent cardioversion of persistent atrial fibrillation ( AF ) were r and omized to bisoprolol 5 to 10 mg once daily or carvedilol 12.5 to 25 mg twice daily . Using intention-to-treat analysis , 23 patients ( 46 % ) in the bisoprolol group and 17 patients ( 32 % ) in the carvedilol group relapsed into AF during the 1 year of total follow-up ( p = 0.486 ) . Patients treated with carvedilol had a 14 % ( hazard ratio 0.86 ) lower risk of relapse of AF compared with patients in the bisoprolol group , although results were statistically insignificant ( p = 0.661 ) after controlling for patient age , gender , baseline heart rate , and left atrial diameter INTRODUCTION We compared the efficacy and safety of amiodarone and dronedarone in patients with persistent atrial fibrillation ( AF ) . METHODS Five hundred and four amiodarone-naïve patients were r and omized to receive dronedarone 400 mg bid ( n = 249 ) or amiodarone 600 mg qd for 28 days then 200 mg qd ( n = 255 ) for at least 6 months . Primary composite endpoint was recurrence of AF ( including unsuccessful electrical cardioversion , no spontaneous conversion and no electrical cardioversion ) or premature study discontinuation . Main safety endpoint ( MSE ) was occurrence of thyroid- , hepatic- , pulmonary- , neurologic- , skin- , eye- , or gastrointestinal-specific events , or premature study drug discontinuation following an adverse event . RESULTS Median treatment duration was 7 months . The primary composite endpoint was 75.1 and 58.8 % with dronedarone and amiodarone , respectively , at 12 months ( hazard ratio [ HR ] 1.59 ; 95 % confidence interval [ CI ] 1.28 - 1.98 ; P < 0.0001 ) , mainly driven by AF recurrence with dronedarone compared with amiodarone ( 63.5 vs 42.0 % ) . AF recurrence after successful cardioversion was 36.5 and 24.3 % with dronedarone and amiodarone , respectively . Premature drug discontinuation tended to be less frequent with dronedarone ( 10.4 vs 13.3 % ) . MSE was 39.3 and 44.5 % with dronedarone and amiodarone , respectively , at 12 months ( HR = 0.80 ; 95 % CI 0.60 - 1.07 ; P = 0.129 ) , and mainly driven by fewer thyroid , neurologic , skin , and ocular events in the dronedarone group . CONCLUSION In this short-term study , dronedarone was less effective than amiodarone in decreasing AF recurrence , but had a better safety profile , specifically with regard to thyroid and neurologic events and a lack of interaction with oral anticoagulants BACKGROUND In biphasic external cardioversion ( CV ) of atrial fibrillation ( AF ) , the influence of different electrode positions on efficacy and incidence of early recurrent atrial fibrillation is not known . This study compared anteroposterior ( AP ) vs anterolateral ( AL ) electrode positioning . METHODS Consecutive patients referred for CV of persistent AF were r and omized either to an AP or an AL electrode position . Biphasic external CV was performed with st and ardized electrode positions and rising energy delivery . RESULTS Both groups ( N = 123 , mean age 66 years , 71 % male , 83 % with structural cardiovascular disease or hypertension ) did not differ concerning age , sex , body mass index , chronic antiarrhythmic therapy , duration of AF  , left ventricular ejection fraction  , and left atrial diameter . Cumulative success rates were comparable ( AP 94.9 % vs AL 95.2 % , P = ns ) . First-shock efficacy did not differ ( AP 78.3 % vs AL 74.6 % , P = ns ) . Early recurrent atrial fibrillation ( AF relapse < 1 minute after successful CV ) occurred in 8.1 % ( AP 11.6 % vs AL 4.8 % , P = ns ) . Mean number of shocks was 1.3 per patient with the AP configuration and 1.4 per patient with the AL configuration ( P = ns ) . Mean cumulative energy delivery was also comparable ( AP 171 WS vs AL 198 WS , P = ns ) . CONCLUSIONS Both electrode positions are similar in biphasic external CV of AF with regard to acute success and early recurrent atrial fibrillation . Also , the number of shocks needed and energy delivery are comparable with both electrode configurations INTRODUCTION Atrial fibrillation ( AF ) and diabetes mellitus type 2 ( DM2 ) often coexist ; however , a small number of patients with DM2 undergoing catheter ablation ( CA ) of AF  have been included in previous studies . The aim of this study was to evaluate safety and efficacy of ablation therapy in DM2 patients with drug refractory AF . METHODS AND RESULTS From January 2005 to September 2006 , 70 patients with a diagnosis of DM2 and paroxysmal ( n = 29 ) or persistent ( n = 41 ) AF were r and omized to receive either pulmonary vein isolation or a new antiarrhythmic drug treatment ( ADT ) with a 1-year follow-up . The primary endpoint was the time to first AF recurrence . By Kaplan-Meier analysis , at the end of follow-up , 42.9 % of patients in the ADT group and 80 % of patients who received a single ablation procedure and were without medications were free of AF ( P = 0.001 ) . In the ablation group , a significant improvement in quality -of-life ( QoL ) scores as compared with ADT group was observed . Six patients in the ADT group ( 17.1 % ) developed significant adverse drug effects . Hospitalization rate during follow-up was higher in the ADT group ( P = 0.01 ) . The only complication attributable to ablation was one significant access-site hematoma . CONCLUSION In patients with DM2 , CA of AF provides significant clinical benefits over the ADT and appears to be a reasonable approach regarding feasibility , effectiveness , and low procedural risk AIMS This study is the first prospect i ve r and omized trial evaluating the efficacy of an antiarrhythmic surgical procedure in patients with chronic atrial fibrillation undergoing mitral valve replacement .  METHODS AND RESULTS Thirty consecutive patients with chronic atrial fibrillation undergoing mitral valve replacement  were r and omized for an additional modified MAZE-operation using intra-operatively cooled-tip radiofrequency ablation ( group A ) or mitral valve replacement alone ( group B ) . Biatrial contraction was studied and functional capacity was evaluated in spiro-ergometry 6 months after surgery . Thirty-day mortality was 0 % in both groups . After 12 months , sinus rhythm was reinstituted significantly more often in patients of group A ( cumulative rate of sinus rhythm 0.800 ) compared to patients in group B ( 0.267 ) ( P<0.01 ) . 66.7 % of patients in sinus rhythm of group A had documented biatrial contraction . Electrocardioversion showed long-term success in only 17 % of patients in group A and 0 % in group B. Maximal aerobic uptake at the 6-month spiro-ergometry revealed no significant difference ( 9.3 vs 8.5 ml x min(-1 ) kg(-1 ) , P=0.530 ) . CONCLUSIONS A modified MAZE operation using cooled-tip radiofrequency ablation can be safely combined with mitral valve surgery and is highly effective in restoring sinus rhythm . Biatrial contraction is found in 66.7 % of patients with sinus rhythm undergoing mitral valve replacement plus the MAZE operation Background : Atrial fibrillation ( AF ) and heart failure ( HF ) often coexist . The aim was to investigate whether restoring sinus rhythm ( SR ) could improve cardiac function , symptoms , exercise capacity and quality of life ( QoL ) in patients with chronic heart failure . Methods : Patients with HF and persistent AF receiving guideline -recommended treatments , including anticoagulants , were eligible for the study . Patients were r and omised to either rhythm ( treated with amiodarone for at least 3 months prior to attempting biphasic external cardioversion and continued amiodarone long-term if SR was restored ) or rate control . Anticoagulants were continued throughout the study regardless of rhythm , unless contraindications developed . Both groups were treated with beta blockers and /or digoxin to reduce the heart rate to < 80 bpm at rest and < 110 bpm after walking . Symptoms , walk distance ( 6-minute corridor walk test , 6MWT ) , QoL and cardiac function were assessed at baseline and 1 year . Results : 61 patients with HF and persistent AF ( median duration 14 months ( IQR 5 to 32 ) ) were r and omly assigned to a rate or rhythm control strategy . Of patients assigned to rhythm control ( n = 30 ) , 66 % were in SR at 1 year , and 90 % of those assigned to rate control ( n = 31 ) achieved the heart rate target . At 1 year , NYHA class ( p = 0.424 ) and 6MWT distance ( p = 0.342 ) were similar between groups but patients assigned to rhythm control had improved LV function ( p = 0.014 ) , NT-proBNP concentration ( p = 0.046 ) and QoL ( p = 0.019 ) compared with those assigned to rate control . Greatest improvement was seen in patients in whom SR was maintained . Conclusion : Restoring SR in patients with AF and heart failure may improve QoL and LV function when compared with a strategy of rate control BACKGROUND Current guidelines for transthoracic direct-current cardioversion ( DCCV ) of atrial fibrillation ( AF ) recommend a step-up energy protocol . The aim of this study was to compare such a protocol with a protocol involving a high initial energy shock , anteroposterior paddle position and reversal of shock polarity , on cardioversion efficacy , total energy delivery , use of sedation and patient tolerability . METHODS 261 patients ( mean age 71+/-10 years , 62 % male ) referred for elective DCCV of persistent AF were enrolled . Patients were r and omised to either protocol A : ( 1 ) 200 J anteroapical , ( 2 ) 360 J anteroapical , ( 3 ) 360 J anteroposterior ; or protocol B : ( 1 ) 360 J anteroapical , ( 2 ) 360 J anteroposterior , and ( 3 ) 360 J posteroanterior . All procedures were performed under sedation with intravenous diazepam . RESULTS Protocol B improved shock success rates ( protocol A first shock success rate=42 % , protocol B=68 % , p<0.001 ; protocol A second shock success rate=72 % , protocol B 86 % , p=0.006 ; protocol A third shock success rate=83 % , protocol B=92 % , p=0.03 ) and required fewer shocks to achieve sinus rhythm ( 1.3+/-0.6 ) compared with protocol A ( 1.6+/-0.7 , p<0.001 ) . There were no differences in cumulative energy used ( protocol A 473+/-286 J , protocol B 436+/-273 J , p=0.24 ) or sedation requirements ( protocol A diazepam 22.1+/-9.0 mg , protocol B 21.7+/-8.9 mg , p=0.75 ) . Both protocol s were equally well tolerated by patients . CONCLUSION High initial energy increased success rates and decreased the number of shocks but result ed in similar cumulative energy delivery , sedation use and patient tolerability compared with a conventional step-up protocol OBJECTIVE To determine the importance of rhythm regulation or rate control in patients with permanent atrial fibrillation ( AF ) and normal left ventricular function . PATIENTS AND INTERVENTIONS Thirty six patients with a mixed fast and slow ventricular response rate to their AF were  r and omised to either His bundle ablation ( HBA ) and VVIR pacemaker ( HBA group ) or VVI pacemaker and atrioventricular modifying drugs ( Med group ) . Outcomes assessed at one , three , six , and 12 months included exercise duration and quality of life . RESULTS Exercise duration significantly improved from baseline in both groups . There was no difference in outcome between the groups ( Med + 40%v HBA + 20 % , p = NS ) . The heart rate profile on exercise was similarly slowed in both groups compared to baseline . Quality of life significantly improved in both treatment arms for the modified Karolinska question naire ( KQ ) ( Med + 50%v HBA + 50 % , p = NS ) and the Nottingham health profile ( NHP ) ( Med + 40 % v HBA + 20 % , p = NS ) . However , for the individual symptom scores of each question naire more were improved in the Med group ( KQ-Med 6 improvedv HBA 4 , NHP-Med 3 vHBA 1 ) . Left ventricular function was equally preserved by both treatments during follow up . CONCLUSION In these patients control of ventricular response rate with either HBA + VVIR pacemaker or atrioventricular modifying drugs + VVI pacemaker will lead to a significant improvement in exercise duration and quality of life . Rhythm regulation by HBA did not confer additional benefit , suggesting rate control alone is necessary for the successful symptomatic treatment of these patients in permanent AF PURPOSE The role of digoxin and verapamil in the control of ventricular response in rapid atrial fibrillation is well established . This study investigates how clonidine compares with these st and ard therapies in rate control for new-onset rapid atrial fibrillation . We set out to test the hypothesis that clonidine effectively reduces heart rate in patients with new-onset rapid atrial fibrillation . SUBJECTS AND METHODS Forty patients were seen in the emergency department with new-onset ( < or = 24 hours ' duration ) , stable , rapid atrial fibrillation . Eligible patients were r and omized to receive either clonidine , digoxin , or verapamil . Changes in heart rate and blood pressure over 6 hours , as well as frequency of conversion to sinus rhythm were recorded and analyzed . RESULTS The mean reduction in heart rate over 6 hours was 44.4 beats/min ( 95 % confidence interval [ CI ] 28.4 - 60.4 beats/min ) in the clonidine group , 52.1 beats/min ( 95 % CI 40.8 - 63.4 beats/min ) in the digoxin group , and 41.8 beats/min ( 95 % CI 22.5 - 61.0 beats/min ) in the verapamil group . Analysis of variance of the heart rate changes in the 3 groups after 6 hours was not significant ( P = .55 ) . At 6 hours , 7 of 12 clonidine patients , 8 of 15 digoxin patients , and 7 of 13 verapamil patients remained in atrial fibrillation ( P = .962 on chi(2 ) ) . CONCLUSION Clonidine controls ventricular rate in new-onset atrial fibrillation with an efficacy comparable to that of st and ard agents BACKGROUND Amiodarone , given as intravenous bolus has not yet been studied in patients with atrial fibrillation and a high ventricular rate . METHODS One hundred consecutive patients with atrial fibrillation and a ventricular rate above 135 bpm were r and omized to receive either 450 mg amiodarone or 0.6 mg digoxin given as a single bolus through a peripheral venous access . If the ventricular rate exceeded 100 bpm after 30 min , another 300 mg amiodarone or 0.4 mg digoxin were added . Primary endpoints of the study were the ventricular rate and the occurrence of sinus rhythm after 30 and 60 min . Secondary endpoints were blood pressure during the first hour after drug administration , and safety regarding drug induced hypotension , and phlebitis at the infusion site . RESULTS Baseline heart rate was 144+/-19 in the amiodarone group and 145+/-15 in the digoxin group ( p=0.72 ) . Following amiodarone , heart rate was 104+/-25 after 30 min compared to 116+/-23 in the digoxin group ( p=0.02 ) and 94+/-22 versus 105+/-22 after 60 min ( p=0.03 ) . After 30 min , sinus rhythm was documented in 14 ( 28 % ) patients following amiodarone compared to 3 ( 6 % ) patients in the digoxin group ( p=0.003 ) , and after 60 min in 21 ( 42 % ) versus 9 ( 18 % ) patients ( p=0.012 ) . Asymptomatic hypotension was observed in 4 amiodarone treated patients , and superficial phlebitis in 1 patient . CONCLUSIONS Amiodarone , given as an intravenous bolus is relatively safe and more effective than digoxin for heart rate control and conversion to sinus rhythm in patients with atrial fibrillation and a rapid ventricular rate STUDY OBJECTIVE A prospect i ve , r and omized controlled trial of new-onset atrial fibrillation was conducted to compare the efficacy and safety of sotalol and amiodarone ( active treatment ) with rate control by digoxin alone for successful reversion to sinus rhythm at 48 hours . METHODS We prospect ively r and omly assigned 120 patients with atrial fibrillation of less than 24 hours ' duration to treatment with sotalol , amiodarone , or digoxin using a single intravenous dose followed by 48 hours of oral treatment . Patients had ECG monitoring for 48 hours , and time of reversion , adequacy of rate control , and numbers of adverse events were compared . After 48 hours , those still in atrial fibrillation underwent cardioversion according to a st and ardized protocol . After 48 hours of therapy and attempted cardioversion , the number of patients whose rhythms had successfully reverted were compared . RESULTS There was a significant reduction in the time to reversion with both sotalol ( 13 . 0+/-2.5 hours , P < .01 ) and amiodarone ( 18.1+/-2.9 hours , P < .05 ) treatment compared with digoxin only ( 26.9+/-3.4 hours ) . By 48 hours , the active treatment group was significantly more likely to have reverted to sinus rhythm than the rate control group ( 95 % versus 78 % , P < .05 ; risk ratio 5.4 , 95 % confidence interval [ CI ] 1.5 to 19.2 ) . In those patients whose rhythms did not revert to sinus rhythm , there was superior ventricular rate control in the sotalol group at both 24 and 48 hours compared with those who received either amiodarone or digoxin . There were also fewer adverse events in the active treatment group compared with the rate control group . CONCLUSION Immediate pharmacologic therapy for new-onset atrial fibrillation with class III antiarrhythmic drugs ( sotalol or amiodarone ) improves complication-free 48-hour reversion rates compared with rate control with digoxin We design ed a prospect i ve , r and omised , single-blind trial to compare the relative efficacy of antero-lateral versus antero-posterior paddle positions for DC cardioversion of persistent atrial fibrillation . A total of 59 patients were r and omised to cardioversion using st and ard gel pads placed either in the antero-lateral ( AL ) or antero-posterior ( AP ) positions . The first synchronised shock was given at 360 J ; if this was unsuccessful , a second shock of 360 J was given in the alternative position . We compared cardioversion success rate and energy requirements with each strategy . With the first 360 J DC shock , a significantly greater proportion of patients were restored to sinus rhythm from the antero-lateral position ( 18/30 ) compared to the antero-posterior position ( 10/29 ) ( P=0.048 ) . For those patients remaining in atrial fibrillation , there was no difference in the proportions cardioverted from the antero-lateral position ( 4/19 ) compared to the antero-posterior position ( 5/12 ) with the second 360 J DC shock ( P=0 . 22 ) . The total cardioversion success rate was 23/30 ( 77 % ) for antero-lateral followed by antero-posterior shocks compared to a success rate of 14/29 ( 48 % ) for antero-posterior followed by antero-lateral shocks , and this difference was significant ( P=0.024 ) . There was no significant difference in the mean energy delivered for patients r and omised to an initial antero-lateral shock ( 504 J ) , compared to patients given an initial antero-posterior shock ( 583 J ) ( P=0.1 ) . We conclude that the antero-lateral paddle position appears more effective for DC cardioversion of persistent atrial fibrillation OBJECTIVE To analyze the efficacy of an IV combination of diltiazem and digoxin vs IV diltiazem alone for acute ventricular rate control in patients with atrial fibrillation . DESIGN Prospect i ve , r and omized , open-label study . PATIENTS AND METHODS Fifty-two patients with atrial fibrillation and uncontrolled ventricular rates were r and omized to receive either an IV combination of diltiazem and digoxin or IV diltiazem alone and were observed for 12 h. The successful rate control was defined as a ventricular rate < 100 beats per minute ( bpm ) persisting for 1 h or conversion to sinus rhythm . The loss of rate control was defined as an increase in the ventricular rate to > 100 bpm persistently for > 30 min or rebound to atrial fibrillation . RESULTS In both treatment arms ( n = 26 each ) , all patients achieved successful and comparable ventricular rate control at 12 h. The mean ( + /- SD ) time taken to achieve successful rate control was shorter in the combination arm ( 15 + /- 16 vs. 22 + /- 22 min ) . Six patients in the combination arm and 11 in the diltiazem-alone arm experienced episodes of loss of rate control . This loss in the combination arm was less than that in the diltiazem-alone arm ( 14 vs 39 episodes ; p = 0.05 ) . The loss of rate control per patient in the combination arm was also less than that in the diltiazem-alone arm ( 2.0 + /- 1.0 vs. 3.5 + /- 1.9 episodes per patient ; p = 0.04 ) . CONCLUSIONS This study demonstrates that in patients with atrial fibrillation who have a rapid ventricular response , the IV combination of diltiazem and digoxin results in a more efficacious ventricular rate control with fewer fluctuations than that achieved by therapy with IV diltiazem alone Aims : To compare the efficacy and safety of an escalating energy protocol with a non-escalating energy protocol using an impedance compensated biphasic defibrillator for direct current cardioversion of atrial fibrillation ( AF ) . Methods and results : This prospect i ve multicentre r and omised trial enrolled 380 patients ( 248 male , mean ( SD ) age 67 ( 10 ) years ) with AF . Patients were r and omised to either an escalating energy protocol ( protocol A : 100 J , 150 J , 200 J , 200 J ) , or a non-escalating energy protocol ( protocol B : 200 J , 200 J , 200 J ) . Cardioversion was performed using an impedance compensated biphasic waveform .  First-shock success was significantly higher for those r and omised to 200 J than 100 J ( 71 % vs 48 % ; p<0.01 ) and for patients with a body mass index ( BMI ) > 25 kg/m2 ( 75 % vs 44 % ; p = 0.01 ) . In patients with a normal BMI there was no significant difference in first-shock success . There was also no significant difference between subsequent shocks or overall success . The use of a non-escalating protocol ( protocol B ) result ed in fewer shocks but with a higher cumulative energy . There was no difference in duration of procedure , amount of sedation administered or post-shock erythema between the groups . Conclusion : First-shock success was significantly higher , particularly in patients with a BMI > 25 kg/m2 , when a non-escalating initial 200 J energy was selected . The overall success , duration of procedure and amount of sedation administered , however , did not differ significantly between the two protocol BACKGROUND External cardioversion is a readily available treatment for persistent atrial fibrillation . Although anatomical and electrophysiological considerations suggest that an anterior-posterior electrode position should create a more homogeneous shock-field gradient throughout the atria than an anterior-lateral position , both electrode positions are equally recommended for external cardioversion in current guidelines . We undertook a r and omised trial comparing the two positions with the endpoint of successful cardioversion . METHODS 108 consecutive patients ( mean age 60 years [ SD 16 ] ) with persistent atrial fibrillation ( median duration 5 months , range 0.1 - 120 ) underwent elective external cardioversion by a st and ardised step-up protocol with increasing shock strengths ( 50 - 360 J ) . Electrode positions were r and omly assigned as anterior-lateral or anterior-posterior . If sinus rhythm was not achieved with 360 J energy , a single cross-over shock ( 360 J ) was applied with the other electrode configuration . A planned interim analysis was done after these patients had been recruited ; it was by intention to treat . FINDINGS Cardioversion was successful in a higher proportion of the anterior-posterior than the anterior-lateral group ( 50 of 52 [ 96 % ] vs 44 of 56 [ 78 % ] , difference 23.7 % ( 95 % CI 9.1 - 37.8 , p=0.009 ) . Cross-over from the anterior-lateral to the anterior-posterior electrode position was successful in eight of 12 patients , whereas cross-over in the other direction was not successful ( two patients ) . After cross-over , cardioversion was successful in 102 of 108 r and omised patients ( 94 % ) . INTERPRETATION An anterior-posterior electrode position is more effective than the anterior-lateral position for external cardioversion of persistent atrial fibrillation . These results should be considered in clinical practice , for the design of defibrillation electrode pads , and when guidelines for cardioversion of atrial fibrillation are up date Background : Electrical direct‐current cardioversion ( DCCV ) has become a routine therapy for atrial fibrillation ( AF ) , although some uncertainty remains regarding the optimal energy setting Background —Ablation of the pulmonary veins ( PVs ) for atrial fibrillation treatment is often combined with linear radiofrequency lesions along the left atrium ( LA ) to improve the success rate . The study was design ed to assess the contribution of LA posterior wall isolation to the outcome of circumferential pulmonary vein ablation ( CPVA ) . Methods and Results —CPVA consisted of continuous radiofrequency lesions encircling both ipsilateral PVs plus an ablation line along the mitral isthmus . Patients were then r and omized into 2 groups . In the first group , superior PVs were connected by linear lesions along the LA roof ( CPVA-1 group ) . In the second group , the LA posterior wall was isolated by adding a second line connecting the inferior aspect of the 2 inferior PVs ( CPVA-2 group ) . The study included 120 patients ( 53±11 years , 77 % male , 60 % paroxysmal atrial fibrillation , LA of 41.3±5.4 mm , 46 % with hypertension , and 22 % with structural heart disease ) . After a single ablation procedure and a mean follow-up of 10±4 months , 24 ( 40 % ) patients of the CPVA-1 group had atrial fibrillation recurrences and 3 ( 5 % ) had new-onset LA flutter . In the CPVA-2  group , recurrences were due to atrial fibrillation episodes in 23 patients ( 38 % ) and LA flutter in 4 ( 7 % ) . Freedom from arrhythmia recurrences was not statistically different in the CPVA-1 group as compared with the CPVA-2 group ( log rank P=0.943 ) . Conclusion —Isolation of the LA posterior wall did not increase the success rate of CPVA OBJECTIVES The aim of this study was to compare -- in patients with persistent and permanent atrial fibrillation (AF)--the  efficacy and safety of left atrial ablation with that of a biatrial approach . BACKGROUND Left atrium-based catheter ablation of AF , although very effective in the paroxysmal form of the arrhythmia , has an insufficient efficacy in patients with persistent and permanent AF . METHODS Eighty highly symptomatic patients ( age , 58.6 + /- 8.9 years ) with persistent ( n = 43 ) and permanent AF ( n = 37 ) , refractory to antiarrhythmic drugs , were r and omized to two different ablation approaches guided by electroanatomical mapping . A procedure including circumferential pulmonary vein , mitral isthmus , and cavotricuspid isthmus ablation was performed in 41 cases ( left atrial ablation group ) . In the remaining 39 patients ( biatrial ablation group ) , the aforementioned approach was integrated by the following lesions in the right atrium : intercaval posterior line , intercaval septal line , and electrical disconnection of the superior vena cava . RESULTS During follow-up ( mean duration 14 + /- 5 months ) , AF recurred in 39 % of patients in the left atrial ablation group and in 15 % of patients in the biatrial ablation group ( p = 0.022 ) . Multivariable Cox regression analysis showed that ablation technique was an independent predictor of AF recurrence during follow-up . CONCLUSIONS In patients with persistent and permanent AF , circumferential pulmonary vein ablation , combined with linear lesions in the right atrium , is feasible , safe , and has a significantly higher success rate than left atrial and cavotricuspid ablation alone OBJECTIVES We compared ablation strategy with antiarrhythmic drug therapy ( ADT ) in patients with paroxysmal atrial fibrillation ( PAF ) . BACKGROUND Atrial fibrillation ( AF ) ablation strategy is superior to ADT in patients with an initial history of PAF , but its role in patients with a long history of AF as compared with ADT remains a challenge . METHODS One hundred ninety-eight patients ( age , 56 + /- 10 years ) with PAF of 6 + /- 5 years ' duration ( mean AF episodes 3.4/month ) who had failed ADT were r and omized to AF ablation by circumferential pulmonary vein ablation ( CPVA ) or to the maximum tolerable doses of another ADT , which included flecainide , sotalol , and amiodarone . Crossover to CPVA was allowed after 3 months of ADT . RESULTS By Kaplan-Meier analysis , 86 % of patients in the CPVA group and 22 % of those in the ADT group who did not require a second ADT were free from recurrent atrial tachyarrhythmias ( AT ) ( p < 0.001 ) ; a repeat ablation was performed in 9 % of patients in the CPVA group for recurrent AF ( 6 % ) or atrial tachycardia ( 3 % ) . At 1 year , 93 % and 35 % of the CPVA and ADT groups , respectively , were AT-free . Ejection fraction , hypertension , and age independently predicted AF recurrences in the ADT group . Circumferential pulmonary vein ablation was associated with fewer cardiovascular hospitalizations ( p < 0.01 ) . One transient ischemic attack and 1 pericardial effusion occurred in the CPVA group ; side effects of ADT were observed in 23 patients . CONCLUSIONS Circumferential pulmonary vein ablation is more successful than ADT for prevention of PAF with few complications . Atrial fibrillation ablation warrants consideration in selected patients in whom ADT had already failed and maintenance of sinus rhythm is desired . ( A Controlled R and omized Trial of CPVA Versus Antiarrhythmic Drug Therapy in for Paroxysmal AF : APAF/01 ; http:// clinical trials.gov/ct/show ; NCT00340314 ) OBJECTIVES The purpose of this study was to determine quality of life ( QOL ) and exercise performance ( EP ) in patients with persistent atrial fibrillation ( AF ) converted to sinus rhythm ( SR ) compared with those remaining in or reverting to AF . BACKGROUND Restoration of SR in patients with AF improving QOL and EP remains controversial . METHODS Patients with persistent AF were r and omized double-blind to amiodarone , sotalol , or placebo . Those not achieving SR at day 28 were cardioverted and classified into SR or AF groups at 8 weeks ( n = 624 ) and 1 year ( n = 556 ) . The QOL ( SF-36 ) , symptom checklist ( SCL ) , specific activity scale ( SAS ) , AF severity scale ( AFSS ) , and EP were assessed . RESULTS Favorable changes were seen in SR patients at 8 weeks in physical functioning ( p < 0.001 ) , physical role limitations ( p = 0.03 ) , general health ( p = 0.002 ) , and vitality ( p < 0.001 ) , and at 1 year in general health ( p = 0.007 ) and social functioning ( p = 0.02 ) . Changes in the scores for SCL severity ( p = 0.01 ) , functional capacity ( p = 0.003 ) , and AFSS symptom burden ( p < 0.001 ) at 8 weeks and in SCL severity ( p < 0.01 ) and AF symptom burden ( p < 0.001 ) at 1 year showed significant improvements in SR versus AF . Symptomatic patients were more likely to have improvement . The EP in SR versus AF was greater from baseline to 8 weeks ( p = 0.01 ) and to 1 year ( p = 0.02 ) . The EP correlated with physical functioning and functional capacity except in the AF group at 1 year . CONCLUSIONS In patients with persistent AF , restoration and maintenance of SR was associated with improvements in QOL measures and EP . There was a strong correlation between QOL measures and EP BACKGROUND Residual gaps due to incomplete ablation lines are known to be the most common cause of recurrent atrial fibrillation ( AF ) after catheter ablation . We hypothesized that any residual potentials at the junction of the left atrium and pulmonary vein ( PV ) , inside the circumferential PV ablation ( CPVA ) lines , would contribute to the recurrence of AF or post-AF ablation atrial flutter ( AFL ) ; therefore , the elimination of these potentials increases AF-/AFL-free survival rates . METHODS AND RESULTS One hundred and two patients with paroxysmal AF ( PAF ) were enrolled and prospect ively r and omized to a group with  ablation of residual potentials  as add-on therapy to  CPVA + PV electrical isolation ( PVI ) ( group 1 , n = 49 ) , or a group without ablation of the residual potentials ( group 2 , n = 53 ) . Post-CPVA residual potentials , inside the ablation lines , were identified by contact bipolar electrode mapping catheter and a detailed 3-dimensional voltage map . Twenty-three patients in group 1 and 18 patients in group 2 had post-CPVA residual potentials ( 46.9 % vs 34.0 % , P = 0.182 ) . The AF-/AFL-free survival rate during follow-up of 23.3 ± 7.9 months was not different in comparisons between the 2 groups ( P = 0.818 ) , and 79.6 % and 81.1 % of the patients in groups 1 and 2 maintained a sinus rhythm ( P = 0.845 ) , respectively . CONCLUSIONS Residual potentials inside CPVA were commonly found in the patients with PAF after CPVA + PVI . Further ablation of residual potentials did not increase the efficacy of catheter ablation in patients with PAF BACKGROUND The present study aim ed to determine whether quality of life ( QOL ) in permanent atrial fibrillation ( AF ) patients would be improved by monotherapy with beta-blocker ( BB ) or calcium antagonist ( CAA ) as compared with digitalis . METHODS AND RESULTS Twenty-nine patients with permanent AF under digitalis were r and omized into BB ( bisoprolol , atenolol or metoprolol ) or CAA ( verapamil ) monotherapy treatment group . Twenty-five were men and the mean age was 67+/-8 years . After the assigned monotherapy , 12 patients received the other monotherapy in a cross-over fashion . Under each treatment , efficacy of rate control was determined by Holter electrocardiogram ( ECG ) , treadmill testing and QOL question naire ( Short Form-36 ( SF-36 ) and Quality of Life of Atrial Fibrillation ( AFQLQ ) ) , and compared with the baseline digitalis treatment . CAA significantly increased mean and minimum heart rate ( HR ) in Holter ECG as compared with digitalis , whereas BB increased only minimum HR . Exercise duration in treadmill testing was significantly prolonged by CAA treatment , although it only tended to be prolonged by BB treatment . CAA but not BB improved role function-physical score of SF-36 , and frequency and severity of symptoms of AFQLQ . CONCLUSION These results indicate that CAA is preferable to digitalis when monotherapy is selected for short-term improvement of QOL and exercise tolerance in patients with permanent AF INTRODUCTION  Early recurrent atrial fibrillation ( ERAF ) after external cardioversion of atrial fibrillation ( AF ) occurs in 12 % to 26 % of patients . Whether biphasic cardioversion has an impact on the incidence of ERAF after cardioversion of AF is unclear . METHODS AND RESULTS Consecutive patients ( n = 216 , mean age 66 years , 71 % male , 88 % with structural cardiovascular disease or hypertension ) underwent cardioversion with a biphasic ( Bi ) or monophasic ( Mo ) shock waveform in r and omized fashion . Energies used were 120 - 150 - 200 - 200 Ws ( Bi ) or 200 - 300 - 360 - 360 Ws ( Mo ) . The two study groups ( Bi vs Mo ) did not differ with regard to age , sex , body mass index , underlying cardiovascular disease , left atrial diameter , left ventricular ejection fraction , duration of AF fibrillation , and antiarrhythmic drug therapy . Mean delivered energy was significantly lower in the Bi group ( Bi : 186 + /- 143 Ws vs Mo : 324 + /- 227 Ws ; P < 0.001 ) . Overall incidence of ERAF ( AF relapse within 1 minute after successful cardioversion ) was 8.9 % and showed no difference between the two groups ( Bi : 8.1 % vs Mo : 9.7 % , P = NS ) . Cardioversion was successful in 95.4 % of patients . The success rate was comparable in both groups ( Bi : 94.3 % vs Mo 96.8 % ; P = NS ) . First shock efficacy did not differ between Bi and Mo ( 76.4 % vs 67.7 % ; P = NS ) . Mean number of shocks were 1.4 shocks per patient in both groups . CONCLUSION Biphasic cardioversion allows comparable success rates with significantly lower energies . However , the incidence of ERAF is not influenced by biphasic cardioversion . With the energies used , biphasic and monophasic shock waveforms are comparable with regard to first shock and cumulative shock efficacy UNLABELLED Biphasic versus Monophasic Cardioversion . INTRODUCTION Cardioversion of atrial fibrillation using monophasic transthoracic shocks occasionally is ineffective . Biphasic cardioversion requires less energy than monophasic cardioversion , but its efficacy in shock-resistant atrial fibrillation is unknown . Thus , we compared the efficacy of cardioversion using biphasic versus monophasic waveform shocks in patients with atrial fibrillation previously refractory to monophasic cardioversion . METHODS AND RESULTS Fifty-six patients with prior failed monophasic cardioversion were r and omized to either a 360-J monophasic damped sinusoidal shock or biphasic truncated exponential shocks at 150 J , followed by 200 J and then 360 J , if necessary . If either waveform failed , patients were crossed over to the other waveform . The primary endpoint was defined as the proportion of patients achieving sinus rhythm following initial r and omized therapy . Stepwise multivariate logistic regression examined independent predictors of shock success , including patient age , sex , left atrial diameter , body mass index , drug therapy , and waveform . Twenty-eight patients were r and omized to the biphasic shocks and 28 to the monophasic shocks .  Sinus rhythm was restored in 61 % of patients with biphasic versus 18 % with monophasic shocks ( P = 0.001 ) . Seventy-eight percent success was achieved in patients who crossed over to the biphasic shock after failing monophasic cardioversion , whereas only 33 % were successfully cardioverted with a monophasic shock after crossover from biphasic shock ( P = 0.02 ) . Overall , 69 % of patients who received a biphasic shock at any point in the protocol were cardioverted successfully , compared to 21 % with the monophasic shock ( P < 0.0001 ) . The type of shock was the strongest predictor of shock success ( P = 0.0001 ) in multivariate logistic regression . CONCLUSION An ascending sequence of 150- , 200- , and 360-J transthoracic biphasic cardioversion shocks are successful more often than a single 360-J monophasic shock . Thus , biphasic shocks should be the recommended configuration of choice for all cardioversions Chronic atrial fibrillation ( AF ) is a common arrhythmia with significant morbidity and mortality . AF has been the subject of considerable attention and intensive clinical research in recent years . Current opinion on the management of AF favors the restoration and maintenance of normal ventricular rhythm . This has several potential benefits , including the alleviation of arrhythmia-associated symptoms and hemodynamic improvements . Maintenance of frequents normalization of ventricular rhythm ( NVR ) can be achieved with antiarrhythmic drug therapy or with AV node radiofrequency ablation ( RFA ) and permanent ventricular pacing . Recent interest has focused on the use of class III antiarrhythmic agents , such as amiodarone hydrochloride . This investigation compared amiodarone to AV node RFA and permanent pacing of the His-bundle area in maintaining NVR in patients with resistant chronic AF . After 12 months of treatment with amiodarone ( 200 to 400 mg/d ) 30 % of patients remained in NVR , 30 % were in transitional phase of improvement , and 40 % showed negative effect . Only a few patients in this group developed ocular or hepatic side effects . On one year follow-up was achieved in 100 % of cases without any clinical ly significant side effects being seen . In conclusion , analysis of the results of this study suggests that low-dose amiodarone is well tolerated in the management of chronic AF in a selected patient population . The more aggressive interventional radiofrequency ablation technique is significantly more effective and more reliable in the long-term clinical treatment of drug-resistant AF Objective : To compare the effectiveness of intravenous ( IV ) diltiazem and metoprolol in the management of rapid ventricular rate in atrial fibrillation ( AF ) . Methods : This prospect i ve , r and omised study was conducted in the Emergency Department of the Uludag University Medical Faculty Hospital , Bursa , Turkey . Forty AF patients with a ventricular rate ⩾120/minute and systolic blood pressure ⩾95 mm Hg were included and r and omised to receive IV diltiazem 0.25 mg/kg ( maximum 25 mg ) or metoprolol 0.15 mg/kg ( maximum 10 mg ) over 2 minutes . Blood pressures and heart rate were measured at 2 , 5 , 10 , 15 , and 20 minutes . Successful treatment was defined as fall in ventricular rate to below 100/minute or decrease in ventricular rate by 20 % or return to sinus rhythm . Results : Between January 2000 and July 2002 , 40 patients ( 18 men , 22 women ) met the inclusion criteria . Of these 20 ( 8 men , 12 women ; mean age 60.2 years , range 31–82 ) received diltiazem and 20 ( 10 men , 10 women ; mean age 64.0 years , range 31–82 ) received metoprolol . The success rate at 20 minutes for diltiazem and metoprolol was 90 % ( n = 18 ) and 80 % ( n = 16 ) , respectively . The success rate at 2 minutes was higher in the diltiazem group . The percentage decrease in ventricular rate was higher in the diltiazem group at each time interval . None of the patients had hypotension . Conclusion : Both diltiazem and metoprolol  were safe and effective for the management of rapid ventricular rate in AF . However , the rate control effect began earlier and the percentage decrease in ventricular rate was higher with diltiazem than with metoprolol BACKGROUND The restoration and maintenance of sinus rhythm is a desirable goal in patients with atrial fibrillation , because the prevention of recurrences can improve cardiac function and relieve symptoms . Uncontrolled studies have suggested that amiodarone in low doses may be more effective and safer than other agents in preventing recurrence , but this agent has not been tested in a large , r and omized trial . METHODS We undertook a prospect i ve , multicenter trial to test the hypothesis that low doses of amiodarone would be more efficacious in preventing recurrent atrial fibrillation than therapy with sotalol or propafenone . We r and omly assigned patients who had had at least one episode of atrial fibrillation within the previous six months to amiodarone or to sotalol or propafenone , given in an open-label fashion . The patients in the group assigned to sotalol or propafenone underwent a second r and omization to determine whether they would receive sotalol or propafenone first ; if the first drug was unsuccessful the second agent was prescribed . Loading doses of the drugs were administered and electrical cardioversion was performed ( if necessary ) within 21 days after r and omization for all patients in both groups . The follow-up period began 21 days after r and omization . The primary end point was the length of time to a first recurrence of atrial fibrillation . RESULTS Of the 403 patients in the study , 201 were assigned to  amiodarone  and 202 to either sotalol ( 101 patients ) or propafenone ( 101 patients ) . After a mean of 16 months of follow-up , 71 of the patients who were assigned to amiodarone ( 35 percent ) and 127 of those who were assigned to sotalol or propafenone ( 63 percent ) had a recurrence of atrial fibrillation ( P<0.001 ) . Adverse events requiring the discontinuation of drug therapy occurred in 18 percent of the patients receiving amiodarone , as compared with 11 percent of those treated with sotalol or propafenone ( P=0.06 ) . CONCLUSIONS Amiodarone is more effective than sotalol or propafenone for the prevention of recurrences of atrial fibrillation INTRODUCTION Pulmonary vein isolation ( PVI ) is an established treatment for paroxysmal atrial fibrillation ( AF ) . The ablation of complex fractionated atrial electrograms ( CFAE ) has emerged as a novel treatment approach . We sought to evaluate the additional effect of CFAE ablation to PVI in paroxysmal AF . METHODS AND RESULTS Ninety-eight patients with paroxysmal AF ( 57 + /- 10 years , 74 male ) were r and omized to the PVI ( n = 48 ) or PVI + CFAE group ( n = 50 ) . After PVI , CFAE ablation was performed in patients with inducible AF in the PVI + CFAE group . The primary endpoint was combined objective ( 7-day Holter ECG ) and subjective ( symptoms ) freedom of atrial tachyarrhythmia 3 months after ablation . Long-term follow-up ( 19 + /- 8 months ) was available in 94 of 98 patients . CFAE ablation was performed in 30 of 50 patients of the PVI + CFAE group . After 3 months , 36 of 48 patients ( 75 % ) in the PVI group and 38 of 50 patients ( 76 % ) in the PVI + CFAE group were in stable sinus rhythm ( P = NS ) . During long-term follow-up ( 19 + /- 8 months ) , 34 of 46 patients ( 74 % ) in the PVI group and 40 of 48 patients ( 83 % ) in the PVI + CFAE group were in sinus rhythm ( P = 0.08 ) . In a subgroup analysis , a significantly better long-term outcome was achieved if inducible AF after PVI had been treated by additional CFAE ablation as compared with PVI only ( sinus rhythm in 25/28 patients ; 89 % vs 22/30 patients 73 % ; P = 0.003 ) . CONCLUSION In the intention-to-treat analysis , additional CFAE ablation did not improve the success rate of PVI in patients with paroxysmal AF . However , during long-term follow-up , patients with still inducible AF after PVI seemed to profit from additional CFAE ablation Background —Whether different ablation strategies affect paroxysmal atrial fibrillation ( AF ) long-term freedom from AF/atrial tachyarrhythmia is unclear . We sought to compare the effect of 3 different ablation approaches on the long-term success in patients with paroxysmal AF . Methods and Results —One hundred three consecutive patients with paroxysmal AF scheduled for ablation and presenting in the electrophysiology laboratory in AF were selected for this study . Patients were r and omized to pulmonary vein antrum isolation ( PVAI ; n=35 ) versus biatrial ablation of the complex fractionated atrial electrograms ( CFAEs ; n=34 ) versus PVAI followed by CFAEs ( n=34 ) . Patients were given event recorders and followed up at 3 , 6 , 9 , 12 , and 15 months postablation . There was no statistical significant difference between the groups in term of sex , age , AF duration , left atrial size , and ejection fraction . At 1 year follow-up , freedom from AF/atrial tachyarrhythmia was documented in 89 % of patients in the PVAI group , 91 % in the PVAI plus CFAEs group , and 23 % in the CFAEs group ( P<0.001 ) after a single procedure and with antiarrhythmic drugs . Conclusion —No difference in terms of success rate was seen between PVAI alone and PVAI associated with defragmentation . CFAEs ablation alone had the smallest impact on AF recurrences at 1-year follow-up . These results suggest that antral isolation is sufficient to treat most patients with paroxysmal AF BACKGROUND Large trials have demonstrated that rate control is an acceptable alternative for rhythm control . However , optimal heart rate during atrial fibrillation ( AF ) remains unknown . Aim of this analysis was to compare outcome between rate control > or = 80 and < 80 beat/min in patients with persistent atrial fibrillation . METHODS In the RAte Control versus Electrical cardioversion for persistent atrial fibrillation study , 522 patients were included , and 256 were r and omized to rate control . This post hoc analysis included patients r and omized to rate control . Patients were divided according to their mean resting heart rate during follow-up , < 80 beat/min ( n = 75 ) or > or = 80 beat/min ( n = 139 ) . The end point , a composite of cardiovascular mortality , heart failure , thromboembolic complications , bleeding , pacemaker implantation , and severe drug side effects , was compared between both groups . RESULTS During follow-up ( 2.3 + /- 0.6 years ) , a significant difference between both groups in heart rate was observed ( 72 + /- 5 vs 90 + /- 8 beat/min ; P < .001 ) . Rate control drugs were not significantly different between both groups . New York Heart Association class and fractional shortening remained unchanged in both groups . There were 17 ( 23 % ) end points in the low heart rate group and 24 ( 17 % ) in the higher heart rate group ( absolute difference , 5.4 [ -7.3 to 8.2 ] ; P = ns ) . Independent predictors for the primary end point were coronary artery disease , digoxin use , and interrupted anticoagulation , not high heart rate . Quality of life was comparable in both groups during follow-up . CONCLUSIONS In patients treated with a rate control strategy  , no differences were observed in terms of cardiovascular morbidity , mortality , and quality of life between the observed differences in level of rate control throughout follow-up OBJECTIVES We sought to assess the impact of  intermittent atrial fibrillation ( AF ) on health-related quality of life ( QoL ) . BACKGROUND Intermittent AF is a common condition with little data on health-related QoL question naires to guide investigational therapies . METHODS Out patients from four centers , with documented AF ( n = 152 ) , completed vali date d QoL question naires ( Medical Outcomes Study Short Form 36 [ SF-36 ] , Specific Activity , Symptom Checklist , Illness Intrusiveness and University of Toronto AF Severity Scales ) . Comparison groups were made up of healthy individuals ( n = 47 ) and four cardiac control groups : published ( n = 78 ) and created for study ( n = 69 ) percutaneous transluminal coronary angioplasty ( PTCA ) ; published heart failure ( n = 216 ) and published postmyocardial infa rct ion ( MI ) ( n = 107 ) . RESULTS Across all domains of the SF-36 , AF patients reported substantially worse QoL than healthy controls ( 1.3 to 2.0 st and ard deviation units ) , with scores of 24 % , 23 % , 16 % and 30 % lower than healthy individuals on measures of physical and social functioning , mental and general health , respectively ( all p < 0.001 ) . Patients with AF were either significantly worse ( p < 0.05 , published controls ) or as impaired ( study controls ) as either PTCA or post-MI patients on all domains of the SF-36 and the same as heart failure controls on SF-36 psychological subscales . Patients with AF were as impaired or worse than study PTCA controls on measures of illness intrusiveness , activity limitations and symptoms . Associations between objective disease indexes and subjective QoL measures had poor correlations and accounted for < 6 % of the total variability in QoL scores . CONCLUSIONS Quality of life is as impaired in patients with intermittent AF as in patients with significant structural heart disease . Patients ' perception of QoL is not dependent on the objective measures of disease severity that are usually employed Objectives : This r and omised trial evaluated if patients with atrial fibrillation ( AF ) and no history of atrial flutter ( AFL ) had any benefit of prophylactic cavotricuspid isthmus block ( CTIB ) in addition to circumferential pulmonary vein ablation ( CPVA ) . Methods : 149 patients with AF ( 54 % paroxysmal ) were r and omised to CPVA and CTIB  ( group CTIB+ , n = 73 ) or  CPVA alone  ( group CTIB− , n = 76 ) . Patients were followed for 12 months with repetitive 7-day Holter monitoring after 3 , 6 and 12 months . Results : Six patients ( 4 % ) had cardiac tamponade , and one patient had a stroke . No difference was found in the cumulative AFL-free rate between the two treatment groups ( CTIB+ : 88 % vs CTIB− : 84 % , hazard ratio ( HR ) 0.80 , 95 % CI ( 0.34 to 1.90 ) , p = 0.61 ) . There was no difference in the cumulative AF-free rate between the groups ( CTIB+ : 34 % vs CTIB− : 32 % , HR 0.93 , 95 % CI ( 0.63 to 1.38 ) , p = 0.71 ) . Overall , 33 % of the patients were free of AF after a single procedure . Including re procedures , a complete or partial beneficial effect was noted in 62 % of the patients at 12 months . At 12-month follow-up , 24 ( 50 % ) patients with documented AF or AFL in the Holter recordings were asymptomatic . Conclusions : It was not possible to demonstrate any beneficial effect of CTIB in addition to CPVA with regard to AFL or AF recurrences during follow-up . Repetitive long-term Holter monitoring demonstrated a 33 % rate of freedom from AF during a 1-year follow-up . Including additional CPVA procedures , a clinical effect was noted in 62 % of the patients at 12 months . Patients with AF or AFL recurrences were often asymptomatic STUDY OBJECTIVES The relative risks and benefits of strategies of rate control vs rhythm control in patients with atrial fibrillation ( AF ) remain to be fully explored . DESIGN The How to Treat Chronic Atrial Fibrillation ( HOT CAFE ) Polish trial was design ed to evaluate in a r and omized , multicenter , and prospect i ve manner the feasibility and long-term outcomes of rate control vs rhythm control strategies in patients with persistent AF . PATIENTS Our study population comprised 205 patients ( 134 men and 71 women ; mean [ + /- SD ] age , 60.8 + /- 11.2 years ) with a mean AF duration of 273.7 + /- 112.4 days . The mean observation period was 1.7 + /- 0.4 years . One hundred one patients were r and omly assigned to the rate control group and received rate-slowing therapy guided by repeated 24-h Holter monitoring . Direct current cardioversion and atrioventricular junctional ablation with pacemaker placement were alternative nonpharmacologic strategies for patients with tachycardia that was resistant to medical therapy . One hundred four patients were r and omized to sinus rhythm restoration and maintenance using serial cardioversion supported by a predefined stepwise antiarrhythmic drug regimen ( ie , disopyramide , propafenone , sotalol , and amiodarone ) . In both groups , thromboembolic prophylaxis followed current guidelines . MEASUREMENTS AND RESULTS At the end of follow-up , 63.5 % of patients in the rhythm control arm remained in sinus rhythm . No significant differences in the composite end point ( ie , all-cause mortality , number of thromboembolic events , or major bleeding ) were found between the rate control group and the rhythm control group ( odds ratio , 1.98 ; 95 % confidence interval , 0.28 to 22.3 ; p > 0.71 ) . The incidence of hospital admissions was much lower in the rate control arm ( 12 % vs 74 % , respectively ; p < 0.001 ) . New York Heart Association functional class improved in both study groups , while mean exercise tolerance , as measured by the maximal treadmill workload , improved only in the rhythm control group ( 5.2 + /- 5.1 vs 7.6 + /- 3.3 metabolic equivalents , respectively ; p < 0.001 ) . The rhythm control strategy led to an increased mean left ventricular fractional shortening ( 29 + /- 7 % vs 31 + /- 7 % , respectively ; p < 0.01 ) . One episode of pulmonary embolism occurred in the rate control group despite oral anticoagulation therapy , while three patients in the rhythm control arm of the study experienced ischemic strokes ( not significant ) . CONCLUSIONS The Polish HOT CAFE study revealed no significant differences in major end points between the rate control group and the rhythm control group BACKGROUND Beta blockers reduce mortality in patients who have chronic heart failure , systolic dysfunction , and are on background treatment with diuretics and angiotensin-converting enzyme inhibitors .  We aim ed to compare the effects of carvedilol and metoprolol on clinical outcome . METHODS In a multicentre , double-blind , and r and omised parallel group trial , we assigned 1511 patients with chronic heart failure to treatment with carvedilol ( target dose 25 mg twice daily ) and 1518 to metoprolol ( metoprolol tartrate , target dose 50 mg twice daily ) . Patients were required to have chronic heart failure ( NYHA II-IV ) , previous admission for a cardiovascular reason , an ejection fraction of less than 0.35 , and to have been treated optimally with diuretics and angiotensin-converting enzyme inhibitors unless not tolerated . The primary endpoints were all-cause mortality and the composite endpoint of all-cause mortality or all-cause admission . Analysis was done by intention to treat . FINDINGS The mean study duration was 58 months ( SD 6 ) . The mean ejection fraction was 0.26 ( 0.07 ) and the mean age 62 years ( 11 ) . The all-cause mortality was 34 % ( 512 of 1511 ) for carvedilol and 40 % ( 600 of 1518 ) for metoprolol ( hazard ratio 0.83 [ 95 % CI 0.74 - 0.93 ] , p=0.0017 ) . The reduction of all-cause mortality was consistent across predefined subgroups . The composite endpoint of mortality or all-cause admission occurred in 1116 ( 74 % ) of 1511 on carvedilol and in 1160 ( 76 % ) of 1518 on metoprolol ( 0.94 [ 0.86 - 1.02 ] , p=0.122 ) . Incidence of side-effects and drug withdrawals did not differ by much between the two study groups . INTERPRETATION Our results suggest that carvedilol extends survival compared with metoprolol OBJECTIVES This study was design ed to compare two treatment strategies in patients with atrial fibrillation(AF ) :  rhythm-control ( restoration and maintenance of sinus rhythm ) and rate-control ( pharmacologic or invasive rate-control and anticoagulation ) . BACKGROUND Atrial fibrillation is the most common arrhythmia . It is unclear whether a strategy of rhythm- or rate-control is better in terms of mortality , morbidity , and quality of life . METHODS The Strategies of Treatment of Atrial Fibrillation ( STAF ) multicenter pilot trial r and omized 200 patients ( 100 per group ) with persistent AF to rhythm- or rate-control .  The combined primary end point was a combination of death , cardiopulmonary resuscitation , cerebrovascular event , and systemic embolism . RESULTS After 19.6 + /- 8.9 months ( range 0 to 36 months ) there was no difference in the primary end point between rhythm-control ( 9/100 ; 5.54%/year ) and rate-control ( 10/100 ; 6.09%/year ; p = 0.99 ) . The percentage of patients in sinus rhythm in the rhythm-control group after up to four cardioversions during the follow-up period ( rate-control group ) was 23 % ( 0 % ) at 36 months . Eighteen primary end points occurred in atrial fibrillation ; only one occurred in sinus rhythm ( p = 0.049 ) . CONCLUSIONS The STAF pilot study showed no differences between the two treatment strategies in all end points except hospitalizations . These data suggest that there was no benefit in attempting rhythm-control in these patients with a high risk of arrhythmia recurrence . It remains unclear whether the results in the rhythm-control group would have been better if sinus rhythm had been maintained in a higher proportion of patients , as all but one end point occurred during AF OBJECTIVE The aim of this study was to assess the feasibility and effectiveness of irrigated radiofrequency ( RF ) modified Maze procedure through a port access approach during mitral valve surgery and evaluate early and mid-term results . MATERIAL AND METHOD During a 16 months time period , 67 patients with chronic atrial fibrillation ( AF ) eligible for port access mitral valve surgery  were r and omly assigned to either Group A , in which they underwent a combined procedure ( N = 33 ) or Group B , in which a valve procedure alone was performed ( N = 34 ) . Both groups were similar in terms of age , sex , valve pathology , duration of AF left atrial diameter and left ventricle function ( P > 0.05 ) . Four had undergone previous operations . RESULTS Median follow-up was 10 months for both groups , 95 % CI ( 9.18 - 10.8 ) . One patient in each group died early postoperatively ( 3 and 2.9 % ) . Two patients required reoperation for bleeding , one in each group ( 3 and 2.9 % ) . There were two conversions to right thoracotomy . In Group A , freedom from AF was 100 % at the end of the operation ( 76 % sinus , 24 % pacemaker ) Six and twelve months freedom from AF was 87.2 and 93.6 % , respectively . In Group B , freedom from AF at the end of operation was 41 % . At the end of 6 and 12 months , freedom from AF was 9.4 % ( P = 0.0001 ) . One patient in Group A required a permanent pacemaker ( 3 % ) . During follow-up , one patient in Group A died of non-cardiac causes ( 3 % ) . In Group B , there were two late deaths : one cardiac ( 2.9 % ) and one neurologic ( 2.9 % ) . There were no thromboembolic events detected in Group A during follow-up , whereas two patients in Group B suffered this complication ( 6 % , P = 0.081 ) . At 12 months , functional capacity had improved for patients in both groups ( P < 0.0001 ) . CONCLUSION The combination of mitral valve surgery and irrigated RF Maze procedure was safe and efficient through a port access approach . There were no procedure related complications like esophageal or coronary artery injury . Early and mid-term results were favourable with 93.6 % of patients free of AF at 1 year in comparison to the 9.4 % of the control group . The data is not sufficient to reach any conclusions in terms of thromboembolic rates , despite favourable results for the RF Maze group . Nevertheless , in terms of feasibilty , sinus rhythm restoration and overall outcome , early results are encouraging and we advocate the use of the combined procedure through a port access approach OBJECTIVES The use of antiarrhythmic drugs after ablation is a controversial issue when evaluating the efficacy of atrial fibrillation ( AF ) ablation . This study compares in a prospect i ve and r and omized fashion the impact of an antiarrhythmic drug in preventing AF recurrence after AF ablation . METHODS From February 2004 to May 2005 , 107 consecutive patients ( mean age 57 + /- 10 years , 69 men ) , with paroxysmal ( 60 % ) or persistent ( 40 % ) drug refractory AF , were r and omly assigned to ablation alone ( Group A , 53 patients ) or combined with the best antiarrhythmic therapy , preferably amiodarone ( Group B , 54 patients ) . All patients underwent cavo-tricuspid and left inferior pulmonary vein (PV)-mitral isthmus ablation plus circumferential PV ablation , using a guided electro-anatomical approach . St and ard electrocardiograms ( ECG ) , and ambulatory and transtelephonic ECG monitoring  were used to assess AF recurrences . Recurrences during the first month after ablation were excluded from this analysis . RESULTS At 12 months of follow-up , no significant difference was observed in the rates of AF recurrences between Group A ( 18/53 patients , 34 % ) and Group B ( 16/54 patients , 30 % ) . The percentage of patients with > /= 1 asymptomatic AF episode was higher in Group B than in Group A ( 10/16 patients , 63 % , vs 5/18 patients , 28 % , P = 0.04 ) . CONCLUSIONS Continuing antiarrhythmic drug therapy in patients who undergo catheter ablation for AF did not lower the rate of AF recurrences . Antiarrhythmic drugs increased the proportion of patients with asymptomatic AF episodes To compare the safety and efficacy of anterior versus posterior approach for atrioventricular ( AV ) junction modification , 40 patients with medically refractory paroxysmal ( PAF ) or chronic atrial fibrillation ( AF ) were r and omly assigned to receive AV junction modification with an anterior or posterior approach . If the ablation session had taken more than 1 hour without success , the alternative ablation approach was attempted . Among the 18 patients assigned to receive the anterior approach , 14 ( 78 % ) had a primary success . One ( 5 % ) patient had complete AV block after ablation . Three patients crossed over to the posterior approach and had a successful outcome . Fourteen ( 64 % ) of 22 patients initially treated with the posterior approach had primary success . One ( 4 % ) patient developed complete AV block . Seven patients crossed over to the anterior approach and had a successful outcome . The primary success rate ( 14/18 vs 14/22 , P = NS ) , incidence of transient AV block ( 3/18 vs 3/22 , P = NS ) , and complete AV block ( 1/18 vs 1/22 , P = NS ) were similar between the anterior approach and posterior approach . The major differences between the two groups showed more radiofrequency pulses ( 10 + /- 4 vs 6 + /- 3 pulses , P < 0.01 ) , longer procedure duration ( 50 + /- 24 vs 28 + /- 18 minutes , P < 0.01 ) , and longer fluoroscopy exposure time ( 28 + /- 17 vs 16 + /- 8 minutes , P < 0.01 ) in the patients who had primary success with the posterior approach . In conclusion , this study demonstrated that ( 1 ) the two techniques had similar efficacies ; ( 2 ) if one approach was ineffective , switching to the other approach might be safe ; ( 3 ) combining these two approaches result ed in overall improvement in the success rate of this procedure , and ( 4 ) the posterior approach needed more radiofrequency pulses , longer procedural time , and longer fluoroscopy exposure time INTRODUCTION Mapping techniques have not been systematic ally evaluated with respect to atypical atrial flutter ( AF ) not involving the inferior vena cava isthmus . The purpose of this study was to assess prospect ively the use of concealed entrainment ( CE ) in mapping of AF and to assess the clinical benefit of ablation of clinical ly relevant atypical AF . METHODS AND RESULTS In seven consecutive patients without prior cardiac surgery presenting with atypical AF , mapping was performed in the right and , if necessary , left atrium . At sites with CE , radiofrequency energy was delivered . In a posthoc analysis , the endocardial activation time , stimulus-flutter wave ( F ) interval , presence of split potentials and diastolic potentials , and postpacing interval were assessed , and effective sites were compared to ineffective sites . A total of 22 forms of atypical AF either could be induced or were present at the time of the study . Eleven of the 13 targeted atypical AFs ( 85 % ) were successfully ablated . The positive predictive value of CE increased from 45 % to 75 % in the presence of matching electrogram-F and stimulus-F intervals or if flutter terminated during entrainment pacing , and to 88 % in the presence of split atrial electrograms or diastolic potentials . During short-term clinical follow-up , none of the patients had recurrence of the ablated AF . However , the majority of patients required either medication for atrial fibrillation or repeated interventions for new forms of AF . CONCLUSION Mapping and ablation of atypical AF is feasible if sites with CE can be identified . However , the clinical benefit of successful ablations in patients with atypical flutter appears to be limited OBJECTIVES This study evaluated the efficacy of antiarrhythmic drugs for the treatment of  atrial fibrillation ( AF ) .  BACKGROUND The most effective and safest antiarrhythmic drug for the treatment of AF is unknown . METHODS The Atrial Fibrillation Follow-up Investigation of Rhythm Management ( AFFIRM ) study compared two treatment strategies -- rate control and rhythm control -- in patients with AF and risk factors for stroke or death . This sub study , performed in patients r and omized to rhythm control , compared different antiarrhythmic drugs by r and omly assigning the first drug treatment to : 1 ) amiodarone , 2 ) sotalol , or 3 ) a class I drug . The primary end point was the proportion of patients alive , in sinus rhythm , with no additional cardioversions and still taking the assigned drug at one year . Comparisons were made between patients eligible for each of three drug pairs . RESULTS At one year , in 222 patients r and omized between amiodarone and class I agents , 62 % were successfully treated with amiodarone , compared with 23 % taking class I agents ( p < 0.001 ) . In 256 patients r and omized between amiodarone and sotalol , 60 % versus 38 % were successfully treated , respectively ( p = 0.002 ) . In 183 patients r and omized between sotalol and class I agents , 34 % versus 23 % were successfully treated , respectively ( p = 0.488 ) , although this portion of the sub study was stopped early when amiodarone was shown to be better than class I agents . Sinus rhythm was achieved in nearly 80 % of patients at one-year follow-up with serial therapy . Adverse effects were common . CONCLUSIONS Amiodarone was more effective at one year than either sotalol or class I agents for the strategy of maintenance of sinus rhythm without cardioversion Biphasic shocks are more effective than damped sine wave monophasic shocks for transthoracic cardioversion ( CV ) of atrial fibrillation ( AF ) , but the optimal protocol for CV with biphasic shocks has not been defined . We conducted a prospect i ve , r and omized study of 120 consecutive patients with persistent AF to delineate the dose-response curve for CV of AF with a biphasic truncated exponential shock waveform and to identify clinical predictors of shock efficacy . Our data suggest that the initial shock energy for CV with this waveform should be 200 J if the patient weighs < 90 kg and 360 J if the patient weighs > /=90 kg INTRODUCTION Isolation of all pulmonary veins ( PV ) is advocated for treatment of paroxysmal atrial fibrillation ( PAF ) . However , the superior PVs are responsible for most AF triggers , whereas the inferior PVs carry the higher risk for ablation-induced ostial stenosis . The aim of this study was to compare a superior PV isolation approach with isolation of all PVs for treatment of PAF . METHODS AND RESULTS Fifty-two patients with PAF were r and omized to either left superior pulmonary vein ( LSPV ) isolation followed by additional isolation of the right superior pulmonary vein ( RSPV ) in case of AF recurrence ( group A , n = 27 ) or isolation of all four PVs followed by a repeat procedure in case of recurrence ( group B , n = 25 ) . At 1-year follow-up , 11 patients ( 41 % ) in group A and 8 patients ( 32 % ) in group B had AF relapse ( P = 0.55 ) . No significant differences in AF relapse were detected between groups at 3 and 12 months ( log rank = 0.36 , P = 0.54 ) and by Cox proportional hazards model analysis ( P = 0.62 ) . Nonsignificant PV stenosis was detected in two patients from group B. Total radiofrequency energy delivery and fluoroscopy and procedure times were lower in group A : 8.9 + /- 1.4 minutes vs 25.6 + /- 3.7 minutes ( P < 0.001 ) , 22.2 + /- 6.8 minutes vs 62 + /- 10.3 minutes ( P < 0.001 ) , and 131.8 + /- 26.5 minutes vs 222.2 + /- 32.3 minutes ( P < 0.001 ) , respectively . CONCLUSION A staged superior PVs isolation approach confers equal success rates but with reduced radiofrequency energy delivery and fluoroscopy and procedure times compared to isolation of all PVs at the initial ablation attempt AIMS Direct current cardioversion of persistent atrial fibrillation is one of the most widely used and effective treatments for the restoration of sinus rhythm , but may be hampered by a low success rate and a high percentage of early recurrence . Pre-treatment with amiodarone or a glucose-insulin-potassium solution could improve the efficacy of electrical cardioversion by reversing the partially depolarized diastolic potential of the subsidiary pacemakers in atrial fibrillation . In a controlled r and omized study , we assessed the effectiveness of electrical cardioversion in patients with persistent atrial fibrillation after pre-treatment with amiodarone or potassium infusion and the efficacy of amiodarone in maintaining sinus rhythm after electrical cardioversion . METHODS AND RESULTS Ninety-two patients with persistent atrial fibrillation ( > 2 weeks duration ) were prospect ively r and omized into three matched groups : A ( n=31 , oral amiodarone 400 mg . day(-1)1 month before and 200 mg . day(-1)2 months after cardioversion ) , B ( n=31 , 180 mg . day(-1)oral diltiazem 1 month before and 2 months after cardioversion and 80 mmol potassium , 50 UI insulin in 500 ml 30 % glucose solution 24 h before cardioversion ) and C ( n=30 , control patients , 180 mg . day(-1)oral diltiazem 1 month before and 2 months after cardioversion ) . Before cardioversion all patients were under 4 weeks effective oral anticoagulant therapy ( warfarin ) . Before electrical cardioversion , the rate of spontaneous conversion to sinus rhythm was higher in group A ( 25 % ) than groups B ( 6 % ) or C ( 3 % ) ( P<0.005 ) . Electrical cardioversion was more successful in group A ( 88 % ) than groups B ( 56 % ) or C ( 65 % ) ( P<0.05 ) , while the electrical thresholds for effective cardioversion were lower in group B than the other groups ( P<0.05 ) . Twenty-four hours after cardioversion , the early recurrence of atrial fibrillation was similar in the three groups ( P = ns ) , while at 2 months the recurrence rate was lower in group A ( 32 % ) than groups B ( 56 % ) or C ( 52 % ) ( P<0.01 ) . CONCLUSION Pre-treatment with low-dose oral amiodarone , compared with oral diltiazem or glucose-insulin-potassium treatments , induces a significantly high percentage of instances of spontaneous conversion , increases electrical cardioversion efficacy and reduces atrial fibrillation recurrence AIM Mitral valve surgery seldom suppresses  atrial fibrillation ( AF )  , present prior to surgery . Maze III surgery eliminates AF in > 80 % of cases , the reason why combining this procedure with mitral valve surgery in patients with AF seems worthwhile . We prospect ively studied the outcome of combining the Maze III procedure with mitral valve surgery . METHODS Thirty-five patients with AF and a mean age of 64 years undergoing mitral valve surgery were prospect ively r and omized according to a 2.5:1 ratio to surgery with ( n=25 ) , or  without ( n=10 ) maze III  and followed for at least 1 year . RESULTS At discharge and after 12 months freedom from AF was 56 % and 92 % , respectively , in the maze group , and 0 % and 20 % , respectively , in patients without maze ( group differences at discharge p=0.002 , after 12 months p=0.0007 ) . Sinus node incompetence was seen in 1 of 25 maze patients requiring pacing . No in-hospital or late death occurred ; stroke was observed in 1 patient ( without maze ) . Quality of life markedly improved after surgery , but did not differ between patients with or without maze surgery . CONCLUSIONS This first prospect i ve r and omized study shows that combining maze III with mitral valve surgery result ed in a significantly better elimination of preoperative AF than mitral valve surgery alone . As the quality of life did not differ between patients with , or without maze surgery , additional maze surgery is primarily recommended in patients in whom anticoagulation therapy can be avoided after surgery , specifically in patients with scheduled mitral valve plasty INTRODUCTION Catheter ablation for paroxysmal atrial fibrillation is widely used for patients with drug-refractory paroxysms of arrhythmia . Recently , novel technologies have been introduced to the market that aim to simplify and shorten the procedure . AIM To compare the clinical outcome of pulmonary vein ( PV ) isolation using a multipolar circular ablation catheter ( PVAC group ) , with point-by-point PV isolation using an irrigated-tip ablation catheter and the CARTO mapping system ( CARTO group ; CARTO , Biosense Webster , Diamond Bar , CA , USA ) . METHODS Patients with documented PAF were r and omized to undergo PV isolation using PVAC or CARTO .  Atrial fibrillation ( AF ) recurrences were documented by serial 7-day Holter monitoring . RESULTS One hundred and two patients ( mean age 58 ± 11 years , 68 men ) were included in the study . The patients had comparable baseline clinical characteristics , including left atrial dimensions and left ventricular ejection fraction , in both study arms ( PVAC : n = 51 and CARTO : n = 51 ) . Total procedural and fluoroscopic times were significantly shorter in the PVAC group ( 107 ± 31 minutes vs 208 ± 46 minutes , P < 0.0001 and 16 ± 5 minutes vs 28 ± 8 minutes , P < 0.0001 , respectively ) . The AF recurrence was documented in 23 % and 29 % of patients in the PVAC and CARTO groups , respectively ( P = 0.8 ) , during the mean follow-up of 200 ± 13 days . No serious complications were noted in both study groups . CONCLUSIONS Clinical success rates of PV isolation are similar when using multipolar circular PV ablation catheter and point-by-point ablation with a three-dimensional ( 3D ) navigation system in patients with PAF , and results in shorter procedural and fluoroscopic times with a comparable safety profile OBJECTIVES This study sought to compare catheter ablation with rate control for persistent atrial fibrillation ( AF ) in heart failure ( HF ) . BACKGROUND The optimal therapy for AF in HF is unclear . Drug-based rhythm control has not proved clinical ly beneficial . Catheter ablation improves cardiac function in patients with HF , but impact on physiological performance has not been formally evaluated in a r and omized trial . METHODS In a r and omized , open-label , blinded-endpoint clinical trial , adults with symptomatic HF , radionuclide left ventricular ejection fraction ( EF ) ≤35 % , and persistent AF were assigned to undergo catheter ablation or rate control . Primary outcome was 12-month change in peak oxygen consumption . Secondary endpoints were quality of life , B-type natriuretic peptide , 6-min walk distance , and EF . Results were analyzed by intention-to-treat . RESULTS Fifty-two patients ( age 63 ± 9 years , EF 24 ± 8 % ) were r and omized , 26 each to ablation and rate control . At 12 months , 88 % of ablation patients maintained sinus rhythm ( single-procedure success 68 % ) . Under rate control , rate criteria were achieved in 96 % . The primary endpoint , peak oxygen consumption , significantly increased in the ablation arm compared with rate control ( difference + 3.07 ml/kg/min , 95 % confidence interval : 0.56 to 5.59 , p = 0.018 ) . The change was not evident at 3 months ( + 0.79 ml/kg/min , 95 % confidence interval : -1.01 to 2.60 , p = 0.38 ) . Ablation improved Minnesota score ( p = 0.019 ) and B-type natriuretic peptide ( p = 0.045 ) and showed nonsignificant trends toward improved 6-min walk distance ( p = 0.095 ) and EF ( p = 0.055 ) . CONCLUSIONS This first r and omized trial of ablation versus rate control to focus on objective exercise performance in AF and HF shows significant benefit from ablation , a strategy that also improves symptoms and neurohormonal status . The effects develop over 12 months , consistent with progressive amelioration of the HF syndrome . ( A R and omised Trial to Assess Catheter Ablation Versus Rate Control in the Management of Persistent Atrial Fibrillation in Chronic Heart Failure ; NCT00878384 ) OBJECTIVE To compare safety and efficacy of 8-mm versus cooled tip catheter in achieving electrical isolation ( EI ) of pulmonary veins ( PV ) for long-term control of  atrial fibrillation ( AF ) .  BACKGROUND There is paucity of studies comparing safety/efficacy of 8-mm and cooled tip catheters in patients undergoing AF ablation . METHODS AND RESULTS This was a r and omized and patient-blinded study . Subjects were followed by clinic visits ( at 6 weeks and 6 months ) and transtelephonic monitoring ( 3-week duration ) done around each visit . Primary endpoints were : ( 1 ) long-term AF control ( complete freedom and /or > 90 % reduction in AF burden on or off antiarrhythmic drugs at 6 months after a single ablation ) , and ( 2 ) occurrence of serious adverse events ( cardiac tamponade , stroke , LA-esophageal fistula , and /or death ) .  Eighty-two patients ( age 56 + /- 9 years , 60 males , paroxysmal AF = 59 ) were r and omized ( 42 patients to 8-mm tip and 40 patients to cooled tip ) . EI of PVs was achieved in shorter time by the 8-mm tip as compared with cooled tip catheter ( 40 + /- 23 minutes vs 50 + /- 30 minutes ; P < 0.05 ) but long-term AF control was not different between the two ( 32 patients [ 78 % ] vs 28 patients [ 70 % ] , respectively ; P = NS ) . One serious adverse event occurred in each group ( LA-esophageal fistula and stroke , respectively ) and no significant PV stenosis was observed in either . CONCLUSION EI of PVs using either 8-mm or cooled tip catheter results in long-term AF control in the majority after a single ablation procedure , with comparable efficacy and safety We conducted a prospect i ve r and omized study to determine the safety and efficacy rate of 3 commonly used energy levels ( 100 , 200 , and 360 J ) for elective direct-current cardioversion  of persistent atrial fibrillation . When compared with 100 and 200 J , the initial success rate with 360 J was significantly higher ( 14 % , 39 % , and 95 % , respectively ) , and patients r and omized to 360 J ultimately required less total energy and a lower number of shocks OBJECTIVES The Atrial Fibrillation Follow-up Investigation of Rhythm Management ( AFFIRM ) functional status sub study aim ed to test the hypothesis that functional status is similar in rate-control and rhythm-control strategies . BACKGROUND R and omized studies , including the AFFIRM study , have failed to demonstrate survival benefits between rate-control and rhythm-control strategies for atrial fibrillation ( AF ) . However , AF may cause functional capacity or cognitive impairment that might justify maintenance of sinus rhythm . METHODS Investigators of the AFFIRM study enrolled 4,060 patients with AF who required long-term therapy and who were 65 years of age or older or who had another risk factor for stroke or death . New York Heart Association functional class ( NYHA-FC ) and Canadian Cardiovascular Society Angina Classification were assessed at initial and each follow-up visit . From 22 r and omly chosen functional status sub study sites , 245 participants underwent  6-min walk tests and Mini-Mental State Examination ( MMSE ) at initial , two-month , and yearly visits . Patients were assigned r and omly to rate-controlling drugs , allowing AF to persist , or rhythm-controlling antiarrhythmic drugs , to maintain sinus rhythm . RESULTS The NYHA-FC worsened with time in both rate-control and rhythm-control groups , with no differences between groups . Presence of AF was associated with worse NYHA-FC ( p < 0.0001 ) . No differences were observed in Canadian Cardiovascular Society Angina Classification or MMSE scores . Six-minute walk distance improved over time in both study arms . On average , walk distance was 94 feet greater in the rhythm-control group ( adjusted p = 0.049 ) . CONCLUSIONS Modest improvement in 6-min walk distance was noted in the rhythm-control arm . Presence of AF was associated with worse NYHA-FC . No difference in cognitive function was detected OBJECTIVES The goal of this study was to evaluate the relationship between the presence of sinus rhythm and outcomes in patients with a history of congestive heart failure ( CHF ) and atrial fibrillation ( AF ) . BACKGROUND The value of sinus rhythm maintenance in patients with AF and heart failure ( HF ) is uncertain . METHODS A total of 1,376 patients with AF , ejection fraction < or = 35 % , and heart failure symptoms were r and omized to a rhythm- or rate-control strategy .  Detailed efficacy analyses were used to evaluate the independent effects of treatment strategy and the presence of sinus rhythm on cardiovascular outcomes . RESULTS Overall , 445 ( 32 % ) patients died and 402 ( 29 % ) experienced worsening HF . The rhythm-control strategy was not predictive of cardiovascular mortality ( hazard ratio [ HR ] : 0.90 , 95 % confidence interval [ CI ] : 0.70 to 1.16 ; p = 0.41 ) , all-cause death ( HR : 0.86 , 95 % CI : 0.69 to 1.08 ; p = 0.19 ) , or worsening HF ( HR : 0.86 , 95 % CI : 0.68 to 1.10 ; p = 0.23 ) . In analyses devised to isolate the effect of underlying rhythm , sinus rhythm was not associated with cardiovascular mortality [ HR : 1.22 , 95 % CI : 0.80 to 1.87 ; p = 0.35 ) , total mortality [ HR : 1.11 , 95 % CI : 0.78 to 1.58 ; p = 0.57 ) , or worsening HF [ HR : 0.62 , 95 % CI : 0.37 to 1.02 ; p = 0.059 ) . CONCLUSIONS A rhythm-control strategy or the presence of sinus rhythm are not associated with better outcomes in patients with AF and CHF OBJECTIVE In this study , we r and omly compared single oral doses of flecainide , amiodarone and propafenone versus placebo for the conversion of  recent atrial fibrillation ( AF ) ( within 48 hours ) . METHODS This is a r and omized prospect i ve , placebo-controlled single-blind study that included 160 consecutive patients with recent AF who were r and omly assigned to single oral doses of flecainide ( 3 mg/kg of weight , n=40 ) , amiodarone ( 30 mg/kg weight , n=40 ) , propafenone ( 8.5 mg/kg of weight , n=40 ) or placebo ( n=40 ) . The primary end-point was conversion rate at 24 hours after the drug intake . The association between antiarrhythmic use and conversion rate was tested with multiple logistic regressions . RESULTS The primary end-point was achieved in 87.5 % of patients with flecainide , 85 % of patients with amiodarone , 85 % of patients with propafenone and 17.5 % of patients with placebo ( p<0.001 compared with placebo for all 3 drugs ) . Conversion rate within 3 hours after drug intake was greater with propafenone ( 57.5 % ) or flecainide ( 45 % ) compared with amiodarone ( 0 % ) or placebo ( 10 % ) . Between 6 and 24 hours , significantly more patients were converted to sinus rhythm with amiodarone than with flecainide or propafenone . The use of antiarrhythmic drugs was a significant predictor of conversion to sinus rhythm compared to placebo ( adjusted OR=19.53 , 95 % CI 3.14 - 121.55 , p<0.001 ) . No serious side effect occurred . CONCLUSION In patients with recent-onset AF , oral flecainide , amiodarone or propafenone are superior to placebo in restoring sinus rhythm within the 24-hour period following the drug intake OBJECTIVES The purpose of this study was to determine if there is a difference in commercially available biphasic waveforms . BACKGROUND Although the superiority of biphasic over monophasic waveforms for external cardioversion of atrial fibrillation ( AF ) is established , the relative efficacy of available biphasic waveforms is less clear . METHODS We compared the effectiveness of a biphasic truncated exponential ( BTE ) waveform and a biphasic rectilinear ( BR ) waveform for external cardioversion of AF . Patients ( N = 188 ) with AF were r and omized to receive transthoracic BR shocks ( 50 , 75 , 100 , 120 , 150 , 200 J ) or BTE shocks ( 50 , 70 , 100 , 125 , 150 , 200 , 300 , 360 J ) . Shock strength was escalated until success or maximum energy dose was achieved . If maximum shock strength failed , patients received the maximum shock of the opposite waveform . Analysis included 141 patients ( 71 BR , 70 BTE ; mean age 66.5 + /- 13.7 . Forty-seven r and omized patients were excluded because of flutter on precardioversion ECG upon blinded review ( n = 25 ) , presence of intracardiac thrombus ( n = 7 ) , or protocol deviation ( n = 15 ) . Groups were similar with regard to clinical and echocardiographic characteristics . RESULTS The success rate was similar for the two waveforms ( 93 % BR vs 97 BTE , P = .44 ) , although cumulative selected and delivered energy was less in the BTE group . Only AF duration was significantly different between successful and unsuccessful patients . No significant complications occurred . CONCLUSIONS Biphasic waveforms were very effective in transthoracic cardioversion of AF , and complication rates were low . No significant difference in efficacy was observed between BR and BTE waveforms . Impedance was not an important determinant of success for either biphasic waveform AIMS Circumferential pulmonary vein isolation ( CPVI ) is an established strategy for atrial fibrillation ( AF ) ablation . Superior vena cava ( SVC ) , by harbouring the majority of non-pulmonary vein ( PV ) foci , is the most common non-PV origin for AF . However , it is unknown whether CPVI combined with SVC isolation ( SVCI ) could improve clinical results and whether SVCI is technically safe and feasible . METHODS AND RESULTS A total of 106 cases ( 58 males , average age 66.0 + /- 8.8 years ) with paroxysmal AF were included for ablation . They were allocated r and omly to two groups : CPVI group ( n = 54 ) and CPVI + SVCI group ( n = 52 ) . All cases underwent the procedure successfully . Pulmonary vein isolation was achieved in all cases . The procedural time and fluoroscopic time were comparable between the two groups . The mean ablation time for SVC was 7.8 + /- 2.7 min . Superior vena cava isolation was obtained in 50/52 cases . In the remaining two cases , SVCI was not achieved because of obviating diaphragmatic nerve injury . During a mean follow-up of 4 + /- 2 months , 12 ( 22.2 % ) cases in the CPVI group and 10 ( 19.2 % ) cases in the CPVI + SVCI group had atrial tachyarrhythmias ( ATa ) recurrence ( P = 0.70 ) . Nine of 12 cases in the CPVI group and 8/10 cases in the CPVI + SVCI group underwent reablation ( P = 0.86 ) , and PV reconnection occurred in 7/9 cases in the CPVI group and in 8/8 cases in the CPVI + SVCI group . All PV reconnection was reisolated by gaps ablation . There was no SVC reconnection in the CPVI + SVCI group . In two cases without PV reconnection from the CPVI group , SVC-originated short run of atrial tachycardia was identified and eliminated by the SVCI . At the end of 12 months of follow-up , 50 cases ( 92.6 % ) in the CPVI group and 49 ( 94.2 % ) in the CPVI + SVC group were free of ATa recurrence ( P = 0.73 ) . CONCLUSION In our series of paroxysmal AF patients , empirically adding SVCI to CPVI did not significantly reduce the AF recurrence after ablation . Superior vena cava isolation may be useful , however , in selected patients in whom the SVC is identified as a trigger for AF . However , because of the preliminary property of the study and its relatively small sample size , the impact of SVCI on clinical results should be evaluated in a large series of patients UNLABELLED Antiarrhythmic agents enhance maintenance of sinus rhythm ( SR ) after direct current cardioversion ( DCC ) for atrial fibrillation but there are few comparative trials . BACKGROUND The aims of the study were ( 1 ) to establish whether patients successfully cardioverted to SR are more likely to stay in SR over 6 months if taking amiodarone or sotalol , and if so , to establish whether one agent is better than the other ; ( 2 ) to establish whether taking amiodarone or sotalol is better at achieving chemical cardioversion within the 6 weeks before DCC ; and ( 3 ) to establish whether DCC is more likely to be successful on a drug . METHODS R and omized , prospect i ve , nonblinded , controlled study of treatment with either amiodarone ( n = 27 ) , sotalol ( n = 36 ) , or no antiarrhythmic agent ( n = 31 ) . RESULTS Chemical cardioversion occurred in 7 patients in the amiodarone group ( A ) , 7 patients in the sotalol group ( S ) , but none in the no-antiarrhythmic group ( N ) . A total of 33 ( 92 % ) patients in the sotalol group , 22 ( 81 % ) patients in the amiodarone group , and 23 ( 74 % ) patients in the no-antiarrhythmic group were in SR after cardioversion . Of the original cohort of patients , 17 ( 63 % ) patients in the amiodarone group remained in SR at 6-month follow-up , compared with 14 ( 39 % ) in the sotalol group and 5 ( 16 % ) in the no-antiarrhythmic group ( A vs N , P < .0002 , P < .0006B [ after Bonferroni correction ] ; A vs S , P = .05 , P = .15B ; and S vs N , P = .03 , P = .09B ) . CONCLUSIONS Amiodarone and sotalol achieved chemical cardioversion before planned electrical cardioversion in 26 % and 19 % of patients , respectively . After successful cardioversion , amiodarone appears better than sotalol at maintaining SR at 6 months BACKGROUND Electric conversion of atrial fibrillation is the most widely used and effective treatment for sinus rhythm restoration . However , it has a limited success rate and a high recurrence rate . HYPOTHESIS Pretreatment with calcium channel blocker may improve the efficacy by reversing the so-called " electric remodeling " phenomenon , also related to overload in cytosolic calcium . METHODS The efficacy of diltiazem or amiodarone pretreatment ( oral , 1 month before and 1 month after conversion ) on direct-current conversion of persistent atrial fibrillation was assessed in 120 patients , r and omly assigned to 3 matched groups : A ( n = 44 , diltiazem ) ; B ( n = 46 , amiodarone ) , and C ( n = 30 , digoxin ) . RESULTS Before electric conversion , all treatments significantly decreased mean heart rate . Spontaneous conversion to sinus rhythm was achieved in 6 % of patients of group A ( 3 of 46 ) versus 25 % of group B ( 11 of 44 ) and 3 % ( 1 of 30 ) of group C ( A/C vs B , P < .005 ) . Current conversion was more successful in group B ( 91 % ) compared with group A ( 76 % ) and group C ( 67 % ) ( B vs A/C , P < .05 ) , with no difference in the electric threshold for effective conversion ( P = not significant ) . At the 24-hour time point , early relapse of atrial fibrillation was similar between groups A and B ( A , 2 % ; B , 3 % ; P = not significant ) and lower than group C ( 12 % ) ( P < .01 ) , whereas at the 1-month time point the recurrence rate was lower in group B ( 28 % ) versus groups A ( 56 % ) and C ( 78 % ) ( B vs A/C , P < .01 ) . No significant side effects were reported . CONCLUSIONS Although diltiazem seems to be as effective as amiodarone in reducing early atrial fibrillation recurrences , diltiazem is less effective in determining spontaneous or electric conversion , with a higher recurrence rate at 2 months . Diltiazem pretreatment could be considered as only a second choice treatment in those patients in whom amiodarone is contraindicated Pretreatment with antiarrhythmic agents could improve cardioversion and recurrence rates in patients with persistent atrial fibrillation . In a prospect i ve controlled trial , 145 patients were r and omly assigned to treatment with carvedilol , amiodarone , or placebo for 4 weeks before electrical cardioversion . Although the 2 drugs had similar effects on cardioversion rates , amiodarone was superior in terms of sinus rhythm maintenance after conversion BACKGROUND Both segmental ostial and circumferential extraostial pulmonary vein ( PV ) isolation have been proven effective in the treatment of atrial fibrillation ( AF ) . However , the recurrence of AF and PV conduction after the 2 ablation strategies has never been compared in a r and omized study . METHODS A total of 100 consecutive patients ( age 56 + /- 10 ; 71 men ) with symptomatic AF ( paroxysmal , 51 ; persistent , 49 ) were r and omized to segmental ostial ( n = 54 ) or circumferential extraostial ( n = 46 ) PV isolation . A circular catheter positioned at the ostium of each target PV guided the ostial PV isolation . Extraostial PV isolation was performed by encircling the paired left and right PVs , respectively , guided by an electroanatomic mapping system . RESULTS A total of 84 % of the patients had recurrent AF after the first PV isolation procedure , showing 72 % with AF and 12 % with organized left atrial tachycardia . In patients undergoing reablation , all but 2 patients had recurrence of left atrium PV conduction ( > 95 % ) . During a mean follow-up of 12 months without antiarrhythmic medication , 57 % of patients who underwent extraostial PV isolation were free of arrhythmia symptoms compared with 31 % of patients who underwent ostial PV isolation ( P < .05 ) . This difference in success rate between the 2 ablation strategies was mainly seen in patients known with persistent AF ( 52 % and 15 % , respectively ; P = .02 ) as opposed to patients with paroxysmal AF ( 65 % and 46 % , respectively ; P = .26 ) . CONCLUSIONS Overall , the more proximal , extraostial PV isolation was found to be superior to ostial PV isolation , especially in patients known with persistent AF . A high recurrence rate of 84 % after a single complete PV isolation procedure was seen . At reablation , more than 95 % had recurrence of left atrium PV conduction regardless of the procedure used , supporting the idea that complete PV isolation seems essential to prevent arrhythmia recurrences The limited efficacy and proarrhythmic risks of antiarrhythmia agents have result ed in alternative therapeutic approaches . Radiofrequency ablation has been reported to be an effective treatment of patients with atrial fibrillation . However , there is no r and omized clinical trial comparing drug and radiofrequency ablation . The authors r and omized 30 patients with chronic atrial fibrillation refractory to medication into amiodarone and radiofrequency ablation .  The primary objective of this study was to compare the efficacy of amiodarone and radiofrequency ablation in the maintenance of sinus rhythm at 1 year after r and omization . Pulmonary vein isolation and linear ablation of right atrium was the technique used for radiofrequency ablation . There were no significant differences in baseline patient characteristics between the 2 groups . The results of this study showed that the probability of free from atrial fibrillation was better in the radiofrequency ablation group compared to amiodarone ( 78.6 % in the ablation group and 40 % in the amiodarone group , p = 0.018 ) . Radiofrequency ablation results in a significant reduction in symptoms relating to atrial fibrillation and a significant improvement in quality of life , whereas amiodarone had no significant effect on symptoms and quality of life . There was an ischemic stroke as a major complication related to radiofrequency ablation . Amiodarone was associated with adverse effects in 46.7 per cent of patients and needed discontinuation in 1 patient . In conclusion , radiofrequency ablation is an effective alternative treatment in patients with atrial fibrillation refractory to medication BACKGROUND The Cox Maze procedure has been used to treat atrial fibrillation in patients with mitral valve disease . Recently , ectopic foci , originating in the pulmonary veins , were demonstrated in patients with atrial fibrillation , and the indication was that their arrhythmia could have a focal origin . In the light of this new evidence , a simplified surgical technique to isolate the pulmonary veins was developed to eliminate permanent atrial fibrillation in patients undergoing mitral valve surgery . This study compares three surgical procedures proposed to maintain sinus rhythm after mitral valve surgery . METHODS A prospect i ve clinical trial of 30 patients with mitral valve disease and permanent atrial fibrillation who had undergone mitral valve surgery were r and omized in accordance with the type of surgery used on each : ( 1 ) . associated en bloc isolation of pulmonary veins , ( 2 ) . the Maze procedure , or ( 3 ) . mitral valve correction alone . The preoperative clinical characteristics were similar in the three groups . RESULTS The overall postoperative complications were similar in all three groups . The cardiopulmonary bypass time and the aortic cross-clamping time were shorter in the control group , but this factor bore no relation to increased morbidity in the intervention groups . The relative risk of atrial fibrillation after surgery was 0.08 in the group undergoing isolation of pulmonary veins ( p = 0.010 ; 95 % confidence interval , 0.01 to 0.71 ) and 0.20 in the Maze group ( p = 0.044 ; 95 % confidence interval , 0.04 to 1.02 ) compared with the control group . CONCLUSIONS En bloc isolation of pulmonary veins associated with mitral valve surgery appears to be safe and just as effective as the Maze procedure in maintaining sinus rhythm in patients with permanent atrial fibrillation This study was performed to evaluate , using a r and omized double-blind , placebo-controlled protocol , the long-term efficacy and safety of propafenone and sotalol in maintaining sinus rhythm after conversion of recurrent symptomatic atrial fibrillation ( AF  )  . The maintenance of sinus rhythm in patients with recurrent AF has several potential benefits , the most important being a reduced risk of thromboembolic events .  Three hundred patients with recurrent AF ( > or = 4 episodes in the last year ) and AF at enrollment lasting < 48 hours were r and omized to receive either propafenone ( mean daily dose 13 + /- 1.5 mg/kg ; 102 patients ) , sotalol ( mean daily dose 3 + /- 0.4 mg/kg ; 106 patients ) , or placebo ( 92 patients ) . After 1-year follow-up , Kaplan-Meier estimates of the proportion of patients remaining in sinus rhythm were comparable between propafenone ( 63 % ) and sotalol ( 73 % ) and superior to placebo ( 35 % ; p = 0.001 vs both drugs ) . Symptomatic recurrences occurred later with propafenone and sotalol than with placebo . Nine patients ( 9 % ) in the propafenone group , 11 ( 10 % ) in the sotalol group , and 3 ( 3 % ) in the placebo group discontinued therapy due to adverse effects . Malignant nonfatal arrhythmias due to proarrhythmic effects were documented with sotalol only , and occurred < 72 hours from the beginning of therapy in 4 patients ( 4 % ) . During recurrences , the ventricular rate was significantly reduced in patients taking propafenone and sotalol ( p = 0.001 for both drugs vs placebo ) . The likelihood of remaining in sinus rhythm during follow-up was higher in younger patients with smaller left atrial size and without concomitant heart disease . In patients with recurrent symptomatic AF , propafenone and sotalol are not significantly different from each other and are superior to placebo in maintaining sinus rhythm at 1 year . Recurrences occur later and tend to be less symptomatic with propafenone and sotalol compared with placebo BACKGROUND R and omized studies evaluating left atrial radiofrequency ablation ( RFA ) in patients with persistent atrial fibrillation undergoing mitral valve surgery are scarce and monocentric . AIM To evaluate the efficacy of left atrial RFA concomitant with mitral valve surgery to restore and maintain sinus rhythm . METHODS The SAFIR is a multicentre , double-blinded , central ly r and omized study involving four university hospitals . Between December 2002 and September 2005 , 43 patients with mitral valve disease and long-st and ing , persistent atrial fibrillation ( duration > 6 months ) were included . We compared valvular surgery alone ( n=22 ) or with left atrial RFA ( n=21 ) . The main endpoint was sinus rhythm at 12 months without recurrence of arrhythmia during follow-up . Secondary endpoints were surgical adverse events , atrial fibrillation relapses , stroke and echocardiographic measurements after three and 12 months ' follow-up . Analyses of the efficacy criteria were performed on an intention-to-treat basis . RESULTS The primary endpoint occurred significantly more often in the RFA group than in the control group ( respectively , 12/21 patients [ 57 % ] vs 1/22 patients [ 4 % ] ; p=0.004 ) . There were more patients with sinus rhythm in the RFA group than in the control group at discharge ( 72.7 % vs 4.8 % ; p<0.005 ) , 3-month follow-up ( 85.7 % vs 23.8 % ; p<0.01 ) and 12-month follow-up ( 95.2 % vs 33.3 % ; p<0.005 ) . The patients in the RFA group had similar rates of postoperative complications and stroke during follow-up as those in the control group . CONCLUSIONS This multicentre study suggests that left atrial RFA is effective and safe in patients with chronic atrial fibrillation and mitral valve disease BACKGROUND Amiodarone and sotalol are commonly used for the maintenance of sinus rhythm , but the efficacy of these agents administered as high-dose infusions for rapid conversion of atrial fibrillation is unknown . Use in this context would facilitate drug initiation in patients in whom ongoing prophylactic therapy is indicated . METHODS We assessed the efficacy and safety of rapid high-dose intravenous infusions of amiodarone and sotalol for heart rate control and rapid reversion to sinus rhythm in patients who came to the emergency department with recent-onset symptomatic atrial fibrillation . Patients ( n = 140 ) were r and omized to receive 1.5mg/kg of sotalol infused in 10 minutes , 10mg/kg of amiodarone in 30 minutes , or 500 microg of digoxin in 20 minutes . Electrical cardioversion was attempted for patients not converting to sinus rhythm within 12 hours . RESULTS The rapid infusion of sotalol or amiodarone result ed in more rapid rate control than digoxin . Each of the 3 trial strategies result ed in similar rates of pharmacological conversion to sinus rhythm  ( amiodarone , 51 % ; sotalol , 44 % ; digoxin , 50 % ; P = not significant ) . The overall rates of cardioversion after trial drug infusion and defibrillation were high for all groups ( amiodarone , 94 % ; sotalol , 95 % , ; digoxin , 98 % ; P = not significant ) , but there was a trend toward a higher incidence of serious adverse reactions in the amiodarone group . CONCLUSION The rapid infusion of sotalol or amiodarone in patients with symptomatic recent-onset atrial fibrillation results in rapid control of ventricular rate . Even with high-dose rapid infusions , all 3 agents are associated with a poor overall reversion rate within 12 hours . Almost all patients were returned to sinus rhythm with a combination of pharmacological therapy and electrical cardioversion CONTEXT Antiarrhythmic drugs are commonly used for prevention of recurrent atrial fibrillation ( AF ) despite inconsistent efficacy and frequent adverse effects . Catheter ablation has been proposed as an alternative treatment for paroxysmal AF . OBJECTIVE To determine the efficacy of catheter ablation compared with antiarrhythmic drug therapy ( ADT ) in treating symptomatic paroxysmal AF . DESIGN , SETTING , AND PARTICIPANTS A prospect i ve , multicenter , r and omized ( 2:1 ) , unblinded , Bayesian- design ed study conducted at 19 hospitals of 167 patients who did not respond to at least 1 antiarrhythmic drug and who experienced at least 3 AF episodes within 6 months before r and omization . Enrollment occurred between October 25 , 2004 , and October 11 , 2007 , with the last follow-up on January 19 , 2009 . INTERVENTION Catheter ablation ( n = 106 ) or ADT ( n = 61 ) , with assessment for effectiveness in a comparable 9-month follow-up period . MAIN OUTCOME MEASURES Time to protocol -defined treatment failure . The proportion of patients who experienced major treatment-related adverse events within 30 days of catheter ablation or ADT was also reported . RESULTS At the end of the 9-month effectiveness evaluation period , 66 % of patients in the catheter ablation group remained free from protocol -defined treatment failure compared with 16 % of patients treated with ADT . The hazard ratio of catheter ablation to ADT was 0.30 ( 95 % confidence interval , 0.19 - 0.47 ; P < .001 ) . Major 30-day treatment-related adverse events occurred in 5 of 57 patients ( 8.8 % ) treated with ADT and 5 of 103 patients ( 4.9 % ) treated with catheter ablation .  Mean quality of life scores improved significantly in patients treated by catheter ablation compared with ADT at 3 months ; improvement was maintained during the course of the study . CONCLUSION Among patients with paroxysmal AF who had not responded to at least 1 antiarrhythmic drug , the use of catheter ablation compared with ADT result ed in a longer time to treatment failure during the 9-month follow-up period . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00116428 AIMS Rate control of atrial fibrillation ( AF ) has become a main treatment modality , but we need more knowledge regarding the different drugs used for this purpose . In this study , we aim ed to compare the effect of four common rate-reducing drugs on exercise capacity and levels of N-terminal pro-B-type natriuretic peptide ( NT-proBNP ) in patients with permanent AF . METHODS AND RESULTS We included 60 patients ( mean age 71 ± 9 years , 18 women ) with permanent AF and normal left ventricular function in a r and omized , cross-over , investigator-blind study . Diltiazem 360 mg , verapamil 240 mg , metoprolol 100 mg , and carvedilol 25 mg were administered o.d . for 3 weeks . At baseline and on the last day of each treatment period , the patients underwent a maximal cardiopulmonary exercise test and  blood sample  s were obtained at rest and at peak exercise . The exercise capacity ( peak VO2 ) was significantly lower during treatment with metoprolol and carvedilol compared with baseline ( no treatment ) or treatment with diltiazem and verapamil ( P < 0.001 for all ) . Compared with baseline , treatment with diltiazem and verapamil significantly reduced the NT-proBNP levels both at rest and at peak exercise , whereas treatment with metoprolol and carvedilol increased the levels ( P < 0.05 for all ) . CONCLUSION Rate-reducing treatment with diltiazem or verapamil  preserved exercise capacity and reduced levels of NT-proBNP compared with baseline , whereas treatment with metoprolol or carvedilol reduced the exercise capacity and increased levels of NT-proBNP BACKGROUND Several different biphasic waveforms are used clinical ly , but few studies have compared their efficacy . The two main waveforms are the biphasic rectilinear ( BR ) and biphasic truncated exponential ( BTE ) waveforms , both of which have important differences , particularly at the extremes of transthoracic impedance . OBJECTIVE To compare the efficacy of two commonly used defibrillation waveforms in the elective cardioversion of atrial fibrillation . METHODS In a prospect i ve r and omized controlled study , sequential adult patients undergoing elective cardioversion for AF were recruited . Patients were r and omized to receive synchronized defibrillation using either a BR or BTE waveform , both using a 50J , 100J , 150J , 200J , 200J selected energy escalating protocol . Failure to cardiovert after the fifth shock was classed as failed defibrillation . The power of this study was 80 % with 5 % significance level to detect a difference of 20 % or greater between groups . Survival analysis was used to compare the total energy delivered to achieve successful cardioversion between groups . RESULTS A total of 202 patients were recruited , of which data are complete for 199 ( 100 BR ; 99 BTE ) .  Median number of shocks to achieve cardioversion was 2 for the BR waveform and 3 for the BTE waveform ( P = 0.059 ) . In the BR waveform group , 95/100 ( 95.0 % ) achieved sinus rhythm . In the BTE waveform group , 90/99 ( 90.9 % ) achieved sinus rhythm and this group required on average 117.1J more energy to achieve the outcome compared to the BR waveform group ( P = 0.838 ) . CONCLUSIONS BR and BTE waveforms show similar high efficacy in the elective cardioversion of atrial fibrillation
target: D. Restoration of sinus rhythm for monophasic vs. biphasic waveforms .
  Another study showed that PVI result ed in long-term restoration
background: Atrial fibrillation ( AF ) is a major public health problem in the United States .
  More than 2.3 million Americans are estimated to have AF ( 1 ) .
  The known association between AF and substantial mortality , morbidity , and health care costs compounds the effect of this condition .
  Not only is the risk for death in patients with AF twice that of patients without it , but AF can result in myocardial ischemia and infa rct ion , exacerbate heart failure ( HF ) , and cause tachycardia-induced cardiomyopathy if the ventricular rate is not well-controlled ( 25 ) .
  The most dreaded complication of AF is thromboembolism , especially stroke ( 6 ) .
  In some patients , AF or therapies to manage this condition can severely depreciate quality of life ( 710 ) .
  Furthermore , the management of AF and its complications is responsible for nearly $ 16 billion in additional costs to the U.S. health care system per year ( 11 ) .
  We conducted this systematic review to evaluate the comparative safety and effectiveness of rate- versus rhythm-control strategies ;  medications used for ventricular rate control ; strict versus more lenient rate-control strategies ; nonpharmacologic rate-control therapies  versus medications ; electrical cardioversion and antiarrhythmic medications  for restoration of sinus rhythm ;  and  catheter ablation , surgical ablation , and antiarrhythmic medications  for maintenance of sinus rhythm .