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AV Junction Ablation and CRT in AF Patients
Study Questions:
In patients with permanent atrial fibrillation (AF) and narrow QRS, is atrioventricular (AV) junction ablation in conjunction with biventricular pacing (cardiac resynchronization therapy [CRT]) superior to pharmacological rate-control therapy in reducing heart failure (HF) and hospitalization?
Methods:
A total of 102 patients with severely symptomatic permanent AF, narrow QRS (≤110 ms), and ≥1 hospitalization for HF were randomized to AV junction ablation and CRT (plus defibrillator according to guidelines) or to pharmacological rate-control therapy (plus defibrillator according to guidelines).
Results:
After a median follow-up of 16 months, the primary composite outcome of death due to HF, or hospitalization due to HF, or worsening HF had occurred in 10 patients (20%) in the Ablation + CRT arm, and in 20 patients (38%) in the Drug arm (hazard ratio [HR], 0.38; 95% confidence interval [CI], 0.18–0.81; p = 0.013). Significantly fewer patients in the Ablation + CRT arm died from any cause or underwent hospitalization for HF (6 [12%] vs. 17 [33%]; HR, 0.28; 95% CI, 0.11–0.72; p = 0.008), or were hospitalized for HF (5 [10%] vs. 13 [25%]; HR, 0.30; 95% CI, 0.11–0.78; p = 0.024). In comparison with the Drug arm, Ablation + CRT patients showed a 36% decrease in the specific symptoms and physical limitations of AF at 1-year follow-up (p = 0.004).
Conclusions:
Ablation + CRT was superior to pharmacological therapy in reducing HF and hospitalization and improving quality of life in elderly patients with permanent AF and narrow QRS.
Perspective:
Prior studies have shown that CRT is superior to right ventricular pacing in patients after AV junction ablation in patients with depressed left ventricular systolic function. In addition to the ultimate control of the ventricular rates, there are hemodynamic benefits from regularization achieved by AV ablation and CRT pacing. Potential enthusiasm about the current study, however, is tempered by the subgroup analysis, which showed that the benefit of ablation plus CRT was significant only in the low ejection fraction patients, did not reach statistical significance in patients with moderate dysfunction, and appeared to have no benefit in patients with normal or near normal left ventricular function. The study was terminated early by the data safety monitoring board, which may have prevented the investigators from demonstrating a benefit. A larger mortality trial of AV nodal ablation and CRT is underway.
Keywords: Arrhythmias, Cardiac, Atrial Fibrillation, Cardiac Resynchronization Therapy, Catheter Ablation, Defibrillators, Geriatrics, Heart Failure, Pharmacology, Quality of Life, Stroke Volume, Systole, Ventricular Function, Left
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