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. A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. Antiarrhythmic efficacy of azimilide in patients with atrial fibrillation. Maintenance of sinus rhythm after conversion to sinus rhythm. Evaluation of outpatient initiation of antiarrhythmic drug therapy in patients reverting to sinus rhythm after an episode of atrial fibrillation. Maintenance of sinus rhythm in patients with atrial fibrillation: an AFFIRM substudy of the first antiarrhythmic drug. Success of serial external electrical cardioversion of persistent atrial fibrillation in maintaining sinus rhythm; a randomized study. Randomized trial of rate-control versus rhythm-control in persistent atrial fibrillation: the Strategies of Treatment of Atrial Fibrillation (STAF) study. Effects of Amiodarone and Diltiazem on Persistent Atrial Fibrillation Conversion and Recurrence Rates: A Randomized Controlled Study A comparison of rate control and rhythm control in patients with atrial fibrillation. What Should be the Primary Treatment in Atrial Fibrillation: Ventricular Rate Control or Sinus Rhythm Control with Long-term Anticoagulation? Use of metoprolol CR/XL to maintain sinus rhythm after conversion from persistent atrial fibrillation: a randomized, double-blind, placebo-controlled study. Antiarrhythmic drug therapy after radiofrequency catheter ablation in patients with atrial fibrillation. Pilsicainide for conversion and maintenance of sinus rhythm in chronic atrial fibrillation: a placebo-controlled, multicenter study. Maintenance of sinus rhythm after electrical cardioversion of persistent atrial fibrillation; sotalol vs bisoprolol. Propafenone versus sotalol for suppression of recurrent symptomatic atrial fibrillation. Natural History and Long-Term Outcomes of Ablated Atrial Fibrillation Efficacy of three different ablative procedures to treat atrial fibrillation in patients with valvular heart disease: a randomised trial.
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 BACKGROUND Maintenance of sinus rhythm is the main therapeutic goal in patients with atrial fibrillation . However , recurrences of atrial fibrillation and side effects of antiarrhythmic drugs offset the benefits of sinus rhythm . We hypothesized that ventricular rate control is not inferior to the maintenance of sinus rhythm for the treatment of atrial fibrillation . METHODS We r and omly assigned 522 patients who had persistent atrial fibrillation after a previous electrical cardioversion to receive treatment aim ed at rate control or rhythm control . Patients in the rate-control group received oral anticoagulant drugs and rate-slowing medication . Patients in the rhythm-control group underwent serial cardioversions and received antiarrhythmic drugs and oral anticoagulant drugs . The end point was a composite of death from cardiovascular causes , heart failure , thromboembolic complications , bleeding , implantation of a pacemaker , and severe adverse effects of drugs . RESULTS After a mean ( + /-SD ) of 2.3+/-0.6 years , 39 percent of the 266 patients in the rhythm-control group had sinus rhythm , as compared with 10 percent of the 256 patients in the rate-control group . The primary end point occurred in 44 patients ( 17.2 percent ) in the rate-control group and in 60 ( 22.6 percent ) in the rhythm-control group . The 90 percent ( two-sided ) upper boundary of the absolute difference in the primary end point was 0.4 percent ( the prespecified criterion for noninferiority was 10 percent or less ) . The distribution of the various components of the primary end point was similar in the rate-control and rhythm-control groups . CONCLUSIONS Rate control is not inferior to rhythm control for the prevention of death and morbidity from cardiovascular causes and may be appropriate therapy in patients with a recurrence of persistent atrial fibrillation after electrical cardioversion BACKGROUND Azimilide dihydrochloride ( azimilide ) is an investigational antiarrhythmic drug that has been tested in patients with a variety of arrhythmias . In patients with atrial fibrillation , it has shown excellent efficacy in some previous trials and minimal efficacy in others . METHODS Patients who had symptomatic atrial fibrillation for > 48 hours but < 6 months were eligible for this multicenter , r and omized , placebo-controlled clinical trial . Patients were admitted to a hospital and r and omly assigned to receive either azimilide 125 mg or a matched placebo twice daily for 3 days and then once daily . Patients who were in sinus rhythm spontaneously or had sinus rhythm restored by electric cardioversion on day 4 were discharged from the hospital .  Recurrence of atrial fibrillation was documented by electrocardiogram . In the primary efficacy analysis , time to recurrence in the 2 treatment groups was compared with the log-rank test in the subgroup of patients with structural heart disease . Safety was assessed as deaths , adverse events , and serious adverse events . RESULTS A total of 446 patients were r and omized in the study ; 314 were in the subgroup with structural heart disease . The median time to arrhythmia recurrence in both treatment groups with structural heart disease was 13 days , and the difference between treatments was not significant ( P = .4596 , n = 314 ) . The relative risk for recurrence ( placebo : azimilide ) was 1.104 ( 95 % CI 0.849 - 1.436 ) . There was 1 death in the placebo group and 3 in the azimilide group . CONCLUSIONS Azimilide did not demonstrate clinical ly important or statistically significant efficacy in reducing the risk for arrhythmia recurrence in patients with structural heart disease who were in atrial fibrillation and converted to sinus rhythm The safety of a method of outpatient antiarrhythmic drug loading utilizing a continuous loop event recorder was evaluated . The findings suggest that the st and ard 2-day hospital admission for drug loading is not necessary in all patients and a method of outpatient loading may be equally safe 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 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 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 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 BACKGROUND There are two approaches to the treatment of atrial fibrillation : one is cardioversion and treatment with antiarrhythmic drugs to maintain sinus rhythm , and the other is the use of rate-controlling drugs , allowing atrial fibrillation to persist . In both approaches , the use of anticoagulant drugs is recommended . METHODS We conducted a r and omized , multicenter comparison of these two treatment strategies in patients with atrial fibrillation and a high risk of stroke or death . The primary end point was overall mortality . RESULTS A total of 4060 patients ( mean [ + /-SD ] age , 69.7+/-9.0 years ) were enrolled in the study ; 70.8 percent had a history of hypertension , and 38.2 percent had coronary artery disease . Of the 3311 patients with echocardiograms , the left atrium was enlarged in 64.7 percent and left ventricular function was depressed in 26.0 percent . There were 356 deaths among the patients assigned to rhythm-control therapy and 310 deaths among those assigned to rate-control therapy ( mortality at five years , 23.8 percent and 21.3 percent , respectively ; hazard ratio , 1.15 [ 95 percent confidence interval , 0.99 to 1.34 ] ; P=0.08 ) . More patients in the rhythm-control group than in the rate-control group were hospitalized , and there were more adverse drug effects in the rhythm-control group as well . In both groups , the majority of strokes occurred after warfarin had been stopped or when the international normalized ratio was subtherapeutic . CONCLUSIONS Management of atrial fibrillation with the rhythm-control strategy offers no survival advantage over the rate-control strategy , and there are potential advantages , such as a lower risk of adverse drug effects , with the rate-control strategy . Anticoagulation should be continued in this group of high-risk patients Recent trials have favoured ventricular rate control in atrial fibrillation ( AF ) management , however the present study investigated whether the restoration and maintenance of sinus rhythm with long-term anticoagulation therapy was superior in terms of embolic events and death in 534 patients with an AF duration > 48 h. Patients were r and omized and received sinus rhythm control with either aspirin ( group 1 ) or warfarin ( group 2 ) , or they were given ventricular rate control ( group 3 ) . Cardioversion to sinus rhythm was attempted in 425 patients and was successful in 387 ( 91.1 % ) of them . After 3 years ' follow-up there were 12 , two and 15 embolic events in groups 1 , 2 and 3 respectively ( significant difference between groups 1 and 2 , and 2 and 3 ) and overall mortalities were four , two and 12 , respectively ( significant difference between groups 2 and 3 ) . It is concluded that patients with an AF duration > 48 h might benefit considerably from sinus rhythm restoration and long-term warfarin therapy in terms of embolic events and mortality OBJECTIVES The primary objective of the present study was to assess the efficacy of metoprolol CR/XL to reduce the risk of relapse after cardioversion of persistent atrial fibrillation to sinus rhythm . BACKGROUND Indirect data from studies with d , l sotalol provide evidence that the beta-blocking effects of the compound are important in maintaining sinus rhythm after cardioversion of atrial fibrillation . METHODS After successful conversion to sinus rhythm , 394 patients with a history of persistent atrial fibrillation were r and omly assigned to treatment with metoprolol CR/XL or placebo . The two treatment groups were similar with respect to all pretreatment characteristics . Patients were seen on an outpatient basis for recording of resting electrocardiogram ( ECG )  after one week , one , three and six months of follow-up or whenever they felt that they had a relapse into atrial fibrillation or experienced an adverse event . RESULTS In the metoprolol CR/XL group , 96 patients ( 48.7 % ) had a relapse into atrial fibrillation compared with 118 patients ( 59.9 % ) in the placebo group ( p = 0.005 ) . Heart rate in patients after a relapse into atrial fibrillation was significantly lower in the metoprolol group ( 98 + /- 23 beats/min ) than in the placebo group ( 107 + /- 27 beats/min ) . The rate of adverse events reported was similar in both groups when the difference in follow-up time was taken into account . CONCLUSIONS The results of this double-blind , placebo-controlled study in patients after cardioversion of persistent atrial fibrillation showed that metoprolol CR/XL was effective in preventing relapse into atrial fibrillation or flutter 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 BACKGROUND Pilsicainide is a newly synthesized antiarrhythmic agent with class Ic properties . Various antiarrhythmic agents have been used to convert atrial fibrillation ( AF ) to sinus rhythm or decrease the rate of relapse of AF . METHODS We r and omly assigned 62 patients with chronic AF to oral treatment of either a  placebo  ( 10 patients ) or  150 mg/day of pilsicainide ( 52 patients ) for 4 weeks before electrical cardioversion . Before oral administration of pilsicainide , 41 patients underwent transesophageal echocardiography  to investigate whether there was thrombus formation in the heart chambers . Patients without pharmacologic defibrillation underwent direct current cardioversion to restore sinus rhythm . After successful cardioversion , all patients continued to receive pilsicainide and were monitored for up to 2 years . RESULTS Before cardioversion , 11 patients in the pilsicainide group ( 21 % ) reverted to sinus rhythm . No patients in the placebo group reverted to sinus rhythm . Direct current cardioversion was performed in 51 patients ; however , 8 patients were not converted to sinus rhythm ( 5 patients receiving pilsicainide , 3 patients receiving placebo ) , and 3 patients needed intracardiac cardioversion to convert to sinus rhythm . Asymptomatic bradyarrhythmias were observed in 5 patients in the pilsicainide group . During the follow-up period , 33 patients ( 71 % ) in the pilsicainide group remained in sinus rhythm at 1 month ; this number decreased to 23 patients ( 49 % ) at 3 months , 20 ( 43 % ) at 6 months , 16 ( 34 % ) at 12 months , 16 ( 34 % ) at 18 months , and 16 ( 34 % ) at 24 months . All patients receiving placebo continued to receive placebo after the cardioversion , and AF recurred a few days after cardioversion in all cases . No independent discriminant variables were identified in the groups between maintenance and nonmaintenance of sinus rhythm . Although no serious side effects regarding pilsicainide have been documented , one patient died of acute myocardial infa rct ion , most likely not related to pilsicainide administration . CONCLUSIONS Pilsicainide is effective in restoring or maintaining sinus rhythm in patients with chronic AF lasting longer than an average duration of 22 months . No major adverse effects were observed 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 Because conventional antiarrhythmic therapy is often ineffective in maintaining sinus rhythm or is associated with adverse side effects in patients with atrial fibrillation ( AF ) , there is a clinical need to test newer agents . One hundred patients with AF who had unsuccessful therapy with 1.9 + /- 1.0 type IA antiarrhythmic agents were r and omized to receive either propafenone ( n = 50 ) or sotalol ( n = 50 ) . Patients were stratified into 4 groups based on AF pattern ( chronic vs paroxysmal ) and left atrial size ( large [ > or = 4.5 cm ] vs small [ < 4.5 ] ) . The proportion of patients remaining in sinus rhythm on each agent was calculated for each group by the Kaplan-Meier method . For patients r and omized to propafenone , 46 + /- 8 % , 41 + /- 8 % and 30 + /- 8 % remained in sinus rhythm at 3 , 6 and 12 months , respectively , after cardioversion . A similar proportion of patients treated with sotalol remained in sinus rhythm at follow-up ( 49 + /- 7 % , 46 + /- 8 % and 37 + /- 8 % at 3 , 6 and 12 months , respectively ; p = NS ) . The proportion of patients remaining in sinus rhythm on propafenone and sotalol was not dependent on arrhythmia pattern or left atrial dimension . Except for constipation that occurred more frequently in patients treated with propafenone , adverse side effects were equally distributed between the 2 therapies . Two patients receiving sotalol died during follow-up . Propafenone and sotalol , 2 new antiarrhythmic agents , were found to be equally effective in maintaining sinus rhythm in 100 patients with recurrent AF . Response rates were not affected by arrhythmia pattern , left atrial size or unsuccessful prior drug therapy . ( ABSTRACT TRUNCATED AT 250 WORDS Background —Atrial  fibrillation ( AF ) ablation  is increasingly used in clinical practice . We aim ed to study the natural history and long-term outcomes of ablated AF . Methods and Results —We followed 831 patients after pulmonary vein isolation ( PVI ) performed in 2005 . We documented clinical outcomes using our prospect i ve AF registry with most recent up date on this group of patients in October 2009 . In the first year after ablation , 23.8 % had early recurrence . Over long-term follow-up ( 55 months ) , only 8.9 % had late arrhythmia recurrence defined as occurring beyond the first year after ablation . Repeat ablations in patients with late recurrence revealed conduction recovery in at least 1 of the previously isolated PVs in all of them and right-sided triggers with isoproterenol testing in 55.6 % . At last follow-up , clinical improvement was 89.9 % ( 79.4 % arrhythmia-free off antiarrhythmic drugs and 10.5 % with AF controlled with antiarrhythmic drugs ) . Only 4.6 % continued to have drug-resistant AF . It was possible to safely discontinue anticoagulation in a substantial proportion of patients with no recurrence in the year after ablation ( CHADS score ⩽2 , stroke incidence of 0.06 % per year ) . The procedure-related complication rate was very low . Conclusions —Pulmonary vein isolation is safe and efficacious for long-term maintenance of sinus rhythm and control of symptoms in patients with drug-resistant AF . It obviates the need for antiarrhythmic drugs , negative dromotropic agents , and anticoagulants in a substantial proportion of patients 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
No other antiarrhythmic showed a significant effect on mortality compared with controls .
Class IA , IC , and III drugs are effective in maintaining sinus rhythm but increase adverse effects , and class IA drugs may increase mortality
BACKGROUND A variety of antiarrhythmic drugs have been used to prevent recurrence of atrial fibrillation after conversion to sinus rhythm .
We performed a systematic review to determine the effect of long-term treatment with those drugs on death , embolisms , adverse effects , and atrial fibrillation recurrence .