Cardiac Resynchronization Therapy in Patients With Atrial Fibrillation: The CERTIFY Study

Study Questions:

How does atrial fibrillation (AF) affect outcomes in patients with heart failure (HF) undergoing cardiac resynchronization therapy (CRT)?


The subjects of CERTIFY, a prospective observational study, were 7,384 patients (mean age 67 years) with HF, ejection fraction (EF) ≤35%, and QRS ≥120 ms, who underwent CRT. Atrioventricular junction ablation (AVJA) was performed in patients with AF if pharmacological rate control was ineffective. The primary endpoint was total mortality in 6,046 patients with sinus rhythm (SR), 895 patients with AF treated with rate-control drugs, and 443 patients with AF who underwent AVJA.


The median duration of follow-up was 37 months. The percentage of biventricular pacing was significantly lower in the AF/drug group (87%) than in the SR (92%) and AF/AVJA (96%) groups. Total mortality did not differ significantly between the SR (6.1%) and the AF/AVJA (6.8%) groups. Mortality was significantly higher in the AF/drug group (11.3%) than in the other two groups. After adjustment for multiple confounding variables, mortality still was significantly higher in the AF/drug group than in the other two groups. The EF improved to a significantly lesser extent in the AF/drug group than in the other two groups.


In patients with HF and AF who undergo CRT, all-cause mortality is higher among patients treated with rate-control drugs than among patients with SR or patients with AF who undergo AVJA.


The results validate the Class IIa recommendation in the American College of Cardiology Foundation/American Heart Association/Heart Rhythm Society device guidelines that AVJA be performed when CRT is used in HF patients who have persistent AF. The major advantage of AVJA over rate-control drugs is a higher percentage of biventricular pacing.

Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Implantable Devices, Acute Heart Failure

Keywords: Heart Failure, Cardiac Resynchronization Therapy

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