Medicine (RMH) - Theses
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ItemAtrial fibrillation and systolic heart failure: the role of myocardial fibrosis and catheter ablation( 2017)Atrial fibrillation and systolic dysfunction are both emerging epidemics in the developed world and both frequently co-exist. Each condition, both individually and in combination, are associated with significantly worsened morbidity and mortality. Both share pathophysiological mechanisms and may promote the progression of each other. Traditional pharmacological therapies for AF have limited efficacy, which is also the case in patients with concurrent systolic dysfunction. Catheter ablation has emerged as an effective treatment for AF with superior outcomes compared to pharmacological rhythm control, the current standard of care. An increasing body of evidence has shown that catheter ablation is feasible and effective in patients with systolic dysfunction. Nonetheless, identifying those patients with systolic impairment likely obtain the greatest benefit from catheter ablation remains a evolving challenge. Additionally, the electrophysiological and structural changes associated with the co-morbid AF and systolic dysfunction is yet to be fully elucidated. The central aim of this thesis is to comprehensively evaluate the role of catheter ablation as a treatment for systolic dysfunction. Following a comprehensive review of the relevant existing literature in this area in Chapter 1, Chapters 2, 3 and 4, of this thesis seek to clinically evaluate the effectiveness of catheter ablation in selected patients with systolic impairment and AF, with a particular focus on utilising advanced imaging techniques such as cardiac magnetic resonance imaging (CMR), as a tool to optimise patent selection, and evaluate treatment outcomes. Secondly in Chapters 5 to 8, this thesis seeks to characterise the electrophysiological and structural characteristics of patients with AF in the setting of systolic impairment and additionally to highlight the limitations and challenges of catheter ablation in persistent AF, with a focus on pulmonary vein electrical activity and the role of intra-procedural adenosine.