Results from the second phase of the APAF-CRT trial showed ablation plus cardiac resynchronization therapy (CRT) compared with pharmacological rate control was superior in reducing mortality in patients with permanent atrial fibrillation (AFib) and narrow QRS who were hospitalized for heart failure, irrespective of their baseline ejection fraction. The findings were presented during ESC Congress 2021 and simultaneously published in the European Heart Journal.

The multi-center, international trial randomized a total of 133 patients (median age of 73 years and 47% women) to either AV junction ablation plus CRT or pharmacological rate control. All enrolled patients had a narrow QRS and at least one hospitalization for heart failure in the previous year. Additionally, all had severely symptomatic permanent AFib (over six months) and were considered unsuitable for AFib ablation or had undergone an AFib ablation that failed. The primary endpoint was death from any cause. The trial was stopped for efficacy at the interim analysis after a median of 29 months of follow-up per patient.

Results showed the primary endpoint occurred in seven patients (11%) in the ablation plus CRT arm and in 20 patients (29%) in the pharmacological arm. The estimated death rates at four years were 14% and 41% in the ablation plus CRT arm and the pharmacological arm, respectively. Researchers also noted that AV junction ablation and CRT reduced the secondary endpoint of the combined risks of death from any cause or hospitalization for heart failure by 60%.

"We hypothesize that the observed benefit was due to the combination of the strict rate control and rate regularization achieved by AV junction ablation, together with biventricular pacing which counteracted the adverse effects of right ventricular pacing," said principal investigator Michele Brignole, MD. "The improvement in survival shown by the APAF-CRT trial supports ablation plus CRT as a first-line therapy in patients with permanent AFib, narrow QRS and previous hospitalization for heart failure."

Clinical Topics: Arrhythmias and Clinical EP, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: ESC Congress, ESC21, Atrial Fibrillation, Catheter Ablation, Arrhythmias, Cardiac, ACC International

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