Long-term outcomes of cardiac resynchronization therapy are worse in patients who require atrioventricular junction ablation for atrial fibrillation than in those with sinus rhythm

Abstract

Background: The aim of the study was to assess the impact of atrial fibrillation (AF) with and without the need for atrioventricular junction (AVJ) ablation on outcomes in patients undergoing cardiac resynchronization therapy (CRT). Methods: A single center cohort of 200 consecutive CRT patients was divided into three groups: 1) AF with CRT pacing < 95% in which AVJ ablation was performed (AF-ABL, n = 40; 20%), 2) AF without the need for AVJ ablation (AF-nonABL, n = 40; 20%), 3) sinus rhythm (SR, n = 120; 60%). All patients were assessed before CRT implantation and at 6-month follow-up. Positive clinical response to CRT was considered alive status without the need for heart transplantation and improvement ≥ 1 NYHA after 6 months. The comparative analysis among all study groups with respect to response-rate and long-term survival was performed. Results: The 6-month response-rate in both AF-ABL and AF-nonABL was significantly lower than in SR (52.5 and 50 vs.77.5%, respectively; both p < 0.017), though there were no differences in baseline characteristics among study groups apart from higher baseline NT-proBNP levels in AF-ABL. However, after adjustment for this confounder, and despite optimal CRT pacing burden in study groups, the remote all-cause mortality during median follow-up of 36.1 months was significantly higher in p = 0.03 (Cardiol J 2014; 21, 3: 309-315)

Outcomes of cardiac resynchronisation therapy in patients with heart failure with atrial fibrillation: a systematic review and meta-analysis of observational studies

“…This meta-analysis included 31 studies4–16 19 27–43 with 83 571 patients. All studies were available as full text.…”

“…Nineteen studies4–9 12 13 19 27–36 with 68 782 patients were included in the meta-analysis of all-cause mortality, and 10 studies4–8 12 13 15 32 33 with 10 628 patients were included in the meta-analysis of cardiovascular mortality. Follow-up period for the studies ranged from 1 to 7 years.…”

“…To assess if AVJ ablation played any role in the mortality outcome of CRT-AF patients, CRT-AF patients from studies with less than 30% of AVJ ablation patients were compared with CRT-NSR patients (17 studies4 5 7–9 12 13 19 27 29–36 with 68 242 patients). This analysis showed significantly higher all-cause mortality in CRT-AF patients compared with CRT-NSR patients (online supplementary figure 7, OR: 1.542, 95% CI 1.341 to 1.774, p=0.000, I 2 =39.187).…”

“…This analysis showed significantly higher all-cause mortality in CRT-AF patients compared with CRT-NSR patients (online supplementary figure 7, OR: 1.542, 95% CI 1.341 to 1.774, p=0.000, I 2 =39.187). Then, mortality difference among CRT-AF patients with and without AVJ ablation was compared (five randomised and non-randomised studies12–14 29 42 with 1969 patients; see online supplementary table 3 for study characteristics). All-cause mortality in CRT-AF patients with AVJ ablation was significantly lower than CRT-AF patients without AVJ ablation (figure 3, OR: 0.485, 95% CI 0.247 to 0.952, p=0.035, I 2 =54.294).…”

Atrial fibrillation in cardiac resynchronization recipients with and without prior arrhythmic history. How much of arrhythmia is too much?

“…This result suggests that even in patients with high CRT pacing burden, or in those who underwent ablation of atrioventricular node, high percent of time spent in AF poses unfavorable prognosis. It corresponds with earlier data on independent detrimental role played by AF in CRT recipients and provokes to further attempt to verify the hypothesis, if aggressive rhythm control would be more beneficial than rate control in this group [24][25][26][27][28].…”