Management of persistent atrial fibrillation following balloon mitral valvotomy: safety and efficacy of low-dose amiodarone.
OBJECTIVE
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia encountered in clinical practice. In developing countries, rheumatic mitral stenosis (MS) is the most frequent underlying condition in patients with AF. Sinus rhythm (SR) is difficult to achieve and maintain in these patients, but would be more easily achieved with reduction of left atrial pressure after successful balloon mitral valvotomy (BMV).


METHODS
Eighty-five patients with persistent AF following BMV received amiodarone (600 mg once daily for two weeks, 200 mg daily thereafter). Electrical cardioversion was performed in those with persistent AF (at six and 12 weeks of drug therapy).


RESULTS
Among patients, 33 (39%) converted with amiodarone alone. Of 52 patients who underwent cardioversion at six weeks, 41 (79%) converted to SR. Overall, 87% of patients converted to SR. None of the 11 patients with persistent AF could be converted to SR, despite a second attempt with direct current (DC) cardioversion at 12 weeks. Those who converted to SR had significantly shorter AF duration (AFD) (2.7+/-1.1 versus 3.2+/-0.7 years) and smaller left atrial (LA) size (50.0+/-7.7 versus 57.9+/-4.7 mm). Patient age, gender, NYHA class, ejection fraction and post-BMV variables were comparable between the two groups. Successful maintenance of SR was possible in 61/74 (82%) patients at a mean follow up of 30.6+/-7.1 months (range: 16-43 months). Again, mean AFD was shorter (1.8+/-0.6 versus 3.0+/-0.7 years) and LA size smaller (48.9+/-7.5 versus 54.7+/-6.9 mm) among those who maintained SR. However, even in patients with AFD > or =2 years, successful conversion and maintenance of SR was possible in 74% and 62% of patients, respectively. Among patients with LA size > or =60 mm (n = 16), the corresponding value were 84% and 77%, respectively. On multivariate analysis, only AFD was a predictor of acute and long-term success. The probability of SR remaining in those with AFD <2 years at 21, 30 and 43 months was 96%, 95% and 94.6%, respectively, while for those with AFD > or =2 years these values were 62%, 48% and 40%.


CONCLUSIONS
Low-dose amiodarone was safe and effective in restoring and maintaining SR in patients with AF and rheumatic heart disease.
Kapoor
Aditya
A
Department of Cardiology, Sanjay Gandhi PGIMS, Lucknow, India.
Kumar
Sudeep
S
Singh
Rakesh K
RK
Pandey
C M
CM
Sinha
Nakul
N
D000328:Adult; D000638:Amiodarone / Q000627:therapeutic use; D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000628:therapy*; D002404:Catheterization; D003131:Combined Modality Therapy; D004305:Dose-Response Relationship, Drug; D004554:Electric Countershock; D005260:Female; D005500:Follow-Up Studies; D006325:Heart Atria / Q000187:drug effects / Q000473:pathology; D006801:Humans; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000601:surgery*; D008946:Mitral Valve Stenosis / Q000628:therapy; D015999:Multivariate Analysis; D011237:Predictive Value of Tests; D012008:Recurrence; D012214:Rheumatic Heart Disease / Q000628:therapy; D013318:Stroke Volume / Q000187:drug effects / Q000502:physiology; D013997:Time Factors; D016896:Treatment Outcome
D000889:Anti-Arrhythmia Agents; D000638:Amiodarone