A strategy to achieve CRT response in permanent atrial fibrillation without obligatory atrioventricular node ablation. Cardiac resynchronization therapy in patients with atrial fibrillation: a 2-year follow-up study. Four-year efficacy of cardiac resynchronization therapy on exercise tolerance and disease progression: the importance of performing atrioventricular junction ablation in patients with atrial fibrillation. Effect of Cardiac Resynchronization on the Incidence of Atrial Fibrillation in Patients With Severe Heart Failure Atrioventricular nodal ablation predicts survival benefit in patients with atrial fibrillation receiving cardiac resynchronization therapy. Comparison of usefulness of cardiac resynchronization therapy in patients with atrial fibrillation and heart failure versus patients with sinus rhythm and heart failure. Assessment of upgrading to biventricular pacing in patients with right ventricular pacing and congestive heart failure after atrioventricular junctional ablation for chronic atrial fibrillation.
BACKGROUND Cardiac resynchronization therapy ( CRT ) is an established method in patients with severe heart failure and wide QRS configuration , particularly during sinus rhythm ( SR ) . In CRT patients with permanent atrial fibrillation ( AF ) , there is no general consensus regarding the need for atrioventricular node ( AVN ) ablation . The aim of this study was to evaluate the benefit of CRT in permanent AF with and without AVN ablation . METHODS New York Heart Association classification , QRS duration , and echocardiographic parameters were assessed before and after CRT with a follow-up of 12 ± 3 months . Two hundred thirty patients in SR and 46 patients with permanent AF of 2.1 ± 0.5 years duration were studied .  AVN ablation was performed only in AF patients with insufficient pharmacological rate control evidence d by ≤80 % ventricular stimulation . RESULTS Fifteen AF patients underwent AVN ablation . Biventricular pacing comparably improved functional status , left ventricular ejection fraction , and left ventricular end-diastolic dimensions in all treated groups . Biventricular stimulation percentage was 10 % lower in pharmacologically treated AF patients over 1 year as compared to patients in SR and to AF patients undergoing AVN ablation , which did not affect outcome in this patient population . CONCLUSION In patients with permanent AF and CRT , an AVN ablation strategy might not be strictly required in all patients INTRODUCTION Atrial fibrillation ( AF ) is the most common arrhythmia in patients with heart failure ( HF ) and represents an important comorbidity in these patients . Cardiac resynchronization therapy ( CRT ) has been shown to be beneficial in patients with HF . Whether patients with AF benefit similarly from CRT as their counterparts in sinus rhythm is controversial . METHODS AND RESULTS We conducted a cohort analysis of 175 patients ( 138 men ; age range 57 - 79 years ) who underwent CRT implantation during 2004 - 2008 in our institution . AF was documented in 66 patients ( 37.7 % of patients , 52 men ) . There were no differences in 1- or 2-year mortality between patients with and without AF ( 13.6 % vs 11.79 % , P = 0.7 ; 25.8 % vs 16.9 % , P = 0.2 , respectively ) . There were no differences between the groups in the rate of complications after CRT implantation or in the rate of appropriate electrical shocks . In the subgroup of AF patients with cardiac resynchronization therapy defibrillator ( CRT-D ) ( n = 32 , 48.5 % ) , the 1-year mortality was 3.1 % as compared to 23.5 % in AF patients with cardiac resynchronization therapy pacemaker ( P = 0.03 ) . This difference was no longer evident after 2 years ( 25.0 % vs 26.5 % , P = 0.8 , respectively ) . Ten patients ( 15.2 % ) with AF underwent atrioventricular ( AV ) node ablation . The 2-year mortality of these patients was 10.0 % as compared to 28.6 % in AF patients who did not undergo AV-node ablation ( P = 0.4 ) . CONCLUSIONS In this study , no difference in mortality appears to exist between patients with or without AF and who undergo CRT implantation . Our findings of the beneficial effects of AV-node ablation and CRT-D in AF patients deserve further investigation OBJECTIVES The goal of this study was to investigate the effects of cardiac resynchronization therapy ( CRT ) in heart failure patients with permanent atrial fibrillation ( AF ) and the role of atrioventricular junction ( AVJ ) ablation . BACKGROUND Cardiac resynchronization therapy has been proven effective in heart failure patients with sinus rhythm ( SR ) . However , little is known about the effects of CRT in heart failure patients with permanent AF . METHODS Efficacy of CRT on ventricular function , exercise performance , and reversal of maladaptive remodeling process was prospect ively compared in 48 patients with permanent AF in whom ventricular rate was controlled by drugs , thus result ing in apparently adequate delivery of biventricular pacing ( > 85 % of pacing time ) , and in 114 permanent AF patients , who had undergone AVJ ablation ( 100 % of resynchronization therapy delivery ) . The clinical and echocardiographic long-term outcomes of both groups were compared with those of 511 SR patients treated with CRT . RESULTS Both SR and AF groups showed significant and sustained improvements of all assessed parameters ( model p < 0.001 for all parameters ) . However , within the AF group , only patients who underwent ablation showed a significant increase of ejection fraction ( p < 0.001 ) , reverse remodeling effect ( p < 0.001 ) , and improved exercise tolerance ( p < 0.001 ) ; no improvements were observed in AF patients who did not undergo ablation . CONCLUSIONS Heart failure patients with ventricular conduction disturbance and permanent AF treated with CRT showed large and sustained long-term ( up to 4 year ) improvements of left ventricular function and functional capacity , similar to patients in SR , only if AVJ ablation was performed Background — Atrial fibrillation/flutter ( AF ) and heart failure often coexist ; however , the effect of cardiac resynchronization therapy ( CRT ) on the incidence of AF and on the outcome of patients with new-onset AF remains undefined . Methods and Results — In the CArdiac REsynchronisation in Heart Failure ( CARE-HF ) trial , 813 patients with moderate or severe heart failure were r and omly assigned to pharmacological therapy alone or with the addition of CRT . The incidence of AF was assessed by adverse event reporting and by ECGs during follow-up , and the impact of new-onset AF on the outcome and efficacy of CRT was evaluated . By the end of the study ( mean duration of follow-up 29.4 months ) , AF had been documented in 66 patients in the CRT group compared with 58 who received medical therapy only ( 16.1 % versus 14.4 % ; hazard ratio 1.05 ; 95 % confidence interval , 0.73 to 1.50 ; P=0.79 ) . There was no difference in the time until first onset of AF between groups . Mortality was higher in patients who developed AF , but AF was not a predictor in the multivariable model ( hazard ratio 1.17 ; 95 % confidence interval , 0.82 to 1.67 ; P=0.37 ) . In patients with new-onset AF , CRT significantly reduced the risk for all-cause mortality and all other predefined end points and improved ejection fraction and symptoms ( no interaction between AF and CRT ; all P>0.2 ) . Conclusions — Although CRT did not reduce the incidence of AF , CRT improved the outcome regardless of whether AF developed BACKGROUND Cardiac resynchronization therapy ( CRT ) benefits patients with advanced heart failure . The role of atrioventricular nodal ( AVN ) ablation in improving CRT outcomes , including survival benefit in CRT recipients with atrial fibrillation , is uncertain . OBJECTIVE The purpose of this study was to assess the impact of AVN ablation on clinical and survival outcomes in a large atrial fibrillation and heart failure population that met the current indication for CRT and to determine whether AVN ablation is an independent predictor of survival in CRT recipients . METHODS Of 154 patients with atrial fibrillation who received CRT-D , 45 ( 29 % ) underwent AVN ablation ( + AVN-ABL group ) , whereas 109 ( 71 % ) received drug therapy for rate control during CRT ( -AVN-ABL group ) . New York Heart Association ( NYHA ) class , electrocardiogram , and echocardiogram were assessed before and after CRT .  Survival data were obtained from the national death and location data base ( Accurint ) . RESULTS CRT comparably improved left ventricular ejection fraction ( 8.1 % + /- 10.7 % vs 6.8 % + /- 9.6 % , P = .49 ) and left ventricular end-diastolic diameter ( -2.1 + /- 5.9 mm vs -2.1 + /- 6.7 mm , P = .74 ) in both + AVN-ABL and -AVN-ABL groups . Improvement in NYHA class was significantly greater in the + AVN-ABL group than in -AVN-ABL group ( -0.7 + /- 0.8 vs -0.4 + /- 0.8 , P = .04 ) . Survival estimates at 2 years were 96.0 % ( 95 % confidence interval [ CI ] 88.6%-100 % ) for + AVN-ABL group and 76.5 % ( 95 % CI 68.1%-85.8 % ) for-AVN-ABL group ( P = .008 ) . AVN ablation was independently associated with survival benefit from death ( hazard ratio [ HR ] 0.13 , 95 % CI 0.03 - 0.58 , P = .007 ) and from combined death , heart transplant , and left ventricular assist device ( HR 0.19 , 95 % CI 0.06 - 0.62 , P = .006 ) after CRT . CONCLUSION Among patients with atrial fibrillation and heart failure receiving CRT , AVN ablation for definitive biventricular pacing provides greater improvement in NYHA class and survival benefit . Larger-scale r and omized trials are needed to assess the clinical and survival outcomes of this therapy The prevalence of atrial fibrillation ( AF ) in patients with heart failure is high , but data about the effects of cardiac resynchronization therapy ( CRT ) in patients with chronic AF are scarce . In this prospect i ve observational study of 263 consecutive patients , CRT was performed in 96 patients ( 37 % ) with chronic AF and 167 patients ( 63 % ) with sinus rhythm ( SR ) .  Echocardiographic and clinical parameters were evaluated at baseline and 3 and 12 months . Reverse left ventricular ( LV ) remodeling is defined as LV end-systolic volume decrease > or = 10 % . Hospitalization rates for heart failure in the year before and after implantation were compared . Baseline characteristics between patients with and without AF were similar , but the AF group had smaller LV end-systolic and end-diastolic volumes and larger left atrial dimensions . New York Heart Association class , 6-minute walking distance , quality -of-life score , LV ejection fraction , and mitral regurgitation improved significantly at 3 and 12 months in both groups , and the changes were similar . Reverse LV remodeling after 3 and 12 months was 74 % and 82 % ( AF group ) versus 77 % and 83 % , respectively ( SR group , p = 0.79 ) . After 1 year , cardioversion had occurred in 25 % of patients with AF . In the year after implantation , significant decreases in hospitalizations for heart failure in both groups ( 84 % and 90 % ) were documented . Long-term mortality was almost equal in both groups . In conclusion , this large-scale study shows that the benefit of CRT in patients with chronic AF and heart failure is similar to that in patients with SR . Patients with chronic AF and heart failure should be considered c and i date s for CRT AIMS Effects of cardiac resynchronization therapy ( CRT ) in patients with right ventricular pacing and congestive heart failure ( CHF ) have only been reported in limited series . CRT in patients with atrial fibrillation remains controversial . Patients with AV junctional ablation offer a unique opportunity to study the effects of CRT in patients with right ventricular pacing combined with atrial fibrillation . The aims of the present study were to evaluate the effects of upgrading to biventricular pacing patients with CHF , permanent atrial fibrillation , and prior ablation of the atrioventricular ( AV ) junction followed by conventional right ventricular pacing . METHODS AND RESULTS We studied 16 consecutive patients with permanent atrial fibrillation treated by AV junctional ablation .  After a mean follow-up of 20+/-19 months ( 6 weeks to 5 years ) they were successfully up grade d to biventricular pacing for severe CHF . Parameters were prospect ively evaluated at baseline and at 6 months . The 14 surviving patients at 6 months demonstrated significant improvement ( P<0.02 ) in New York Heart Association class but the exercise test parameters remained unchanged . Cardiothoracic ratio decreased by 5 % ( P=0.04 ) , end-systolic diameter by 8 % ( P=0.001 ) , end-diastolic diameter by 4 % ( P=0.08 ) , systolic pulmonary artery pressure by 17 % ( P<0.0001 ) and mitral regurgitation area by 40 % ( P<0.05 ) . Ejection fraction increased by 17 % ( P=0.11 ) and fractional shortening by 24 % ( P=0.01 ) . CONCLUSION CRT improves left ventricular performance and functional status in patients with permanent atrial fibrillation and prior remote right ventricular pacing
AV nodal ablation was associated with a substantial reduction in all-cause mortality and cardiovascular mortality and with improvements in New York Heart Association functional class compared with medical therapy in CRT-AF patients .
OBJECTIVES The aim of this study was to systematic ally review the medical literature to evaluate the impact of AV nodal ablation in patients with heart failure and coexistent atrial fibrillation ( AF ) receiving cardiac resynchronization therapy ( CRT ) .
BACKGROUND CRT has a substantial evidence base in patients in sinus rhythm with significant systolic dysfunction , symptomatic heart failure , and prolonged QRS duration .
The role of CRT is less well established in AF patients with coexistent heart failure .
AV nodal ablation has recently been suggested to improve outcomes in this group .