The acute clinical effects of rhythm control on elderly patients with long-standing atrial fibrillation, severe tricuspid regurgitation, and right heart failure: a multicenter prospective cohort study

Abstract Background The detrimental effects of long-standing-atrial fibrillation (LS-AF) on left-heart-functions and recuperation of heart-failure (HF) indices by re-initiation of Sinus-rhythm (SR) is well established. However, data is scarce about the effects of AF on right heart functions and their reversibility. Elderly subjects with right-sided-HF symptoms are a high-risk subgroup with limited diastolic-reserves and might be severely affected by the hemodynamic consequences of AF. Purpose To elucidate the acute effects of SR conversion in elderly patients with clinical signs and symptoms of right-sided-heart-failure (RSHF) and LS-AF Methods Adult patients >65 yo with LS-AF and RSHF findings (NYHA ≥2, ≥ 2/4 tricuspid-insufficiency, BNP>400pg/ml, echocardiographic indices of diminished right-heart functions and normal-LVEF) were prospectively evaluated for DC-cardioversion (DCCV). Patients with active coronary-ischemia, severe left-valvular-heart-disease, Group I or IV pulmonary-hypertension, detected thrombus on trans-esophageal-echocardiography and not receiving guideline-mediated-optimal-HF-therapy were excluded. Patients who declined DCCV were followed-up with rate-control strategy. The symptoms, BNP levels, echocardiography and surface 12-lead ECG were re-evaluated in the 1st and 3rd months. All ECGs and echocardiographies were interpreted by two experienced cardiologists in the core-echo-lab. Results After the exclusion criteria were applied 46 subjects ([mean±SD] age, 74.6±8, [range]66-82 years) (female[%overall]: [74%]) agreed to DCCV and 16 subjects ([mean±SD] age, 80.1±13, [range]67-93 years, female 69%) were followed-up with rate control strategy and enrolled. Five lost in follow up. The clinical characteristics of rate and rhythm control subjects are presented in Table-1. SR was achieved in all rhythm-control patients at baseline; however AF recurred on 5 patients in the 1st and 4 more in the 3rd months(SR in 78.6%). Inter and intra-group clinical, echocardiographic and laboratory progression of rhythm and rate control populations are presented on Table-2. In summary, the rhythm-control-group demonstrated significant symptomatic (median baseline NYHA Class II vs I in 3rd month), laboratory (BNP [mean pg/ml] 456 ± 260 vs 125± 78 p= 0.01) and right-heart-functional-echocardiographic benefit compared with rate-control-group and self-control baseline indices. There was a non-significant but slightly positive-trend for the recuparation of indices also in the rate-control-group. Conclusions The relation between right-heart functions and AF is poorly defined and data is generally focused on left-heart related clinics. Our data might suggest, the beneficial effects of rhythm control, especially in a vulnerable elderly population without left heart disease, could demonstrate its efficiency earlier and more evidently in right-heart-failure than we expect in left-heart related positive remodeling after resumption of SR.