Cardiac Resynchronisation Therapy in Heart Failure Patients with Atrial Fibrillation
despite one or more years of continuous AF. However, only a few anecdotal case reports of SR resumption (SRR) of permanent AF after CRT have been described.34
A recent large multicentre, retrospective analysis by Gasparini et al.35 demonstrated an approximate 10% rate of spontaneous (i.e. without cardioversion or anti-arrhythmic drug) return of durable SR, usually within six months of implantation.
The factors that predicted the return of SR included smaller left atrial dimension, smaller LV dimension, shorter QRS duration during CRT and treatment by AVJ ablation. The first two factors suggest better pre-CRT characteristics but cannot be controlled. A shorter QRS suggests less residual dyssynchrony during CRT, but limitations of current LV lead implantation techniques and the inherent restricted opportunities imposed by patient venous anatomy make this difficult to control. The co-existence of three predictors versus none to two predictors increases the likelihood of SRR 3.5-fold, while the presence of all four factors improves the probability by a factor of 5.7. Critically, the subgroup of those who resumed SR went on to have a superb prognosis and a much lower death rate than those who remained in AF (0 versus 18 per 100 person-years). These data may demonstrate an ameliorated prognosis and an increase in survival rate in patients resuming SR after CRT (and AVJ ablation). It may also indicate a need to implant an atrial lead in AF patients undergoing CRT, especially those with three or four of the above-mentioned characteristics.
1. 2. 3. 4. 5. 6. 7. 8. 9.
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The Need for Randomised, Controlled Clinical Trials
There are two ongoing trials aiming to investigate the benefits of adding AVJ ablation to CRT in HF patients with AF: the Atrio-VEntricular Junction Ablation Followed by Resynchronization Therapy in Patients With Congestive Heart Failure and Atrial Fibrillation36
Ablation in Cardiac Resynchronisation Therapy (An-Art) study.37
and the AV Node They
are both concerned with understanding how AVJ ablation coupled with BIV pacing may significantly improve functional capacity compared with pharmacological therapy in HF patients with permanent AF and depressed EF. Data from these two trials, together with the previous large non-randomised experience,17,18
could better clarify the
usefulness of the different strategies in AF patients with HF treated with CRT.
Conclusions
The AF burden in HF patients has a significant negative impact on the clinical benefit of CRT. AVJ ablation is a fundamental weapon at the disposal of physicians: it helps to achieve full CRT delivery, enabling marked improvements in global cardiac function and in overall survival. However, it is of paramount importance for the adjustment of diagnostic and therapeutic strategies to utilise sophisticated and precise instruments to define the degree of AF burden. Only with tailored treatment approaches, can any single AF patient may be correctly treated with CRT in order to attain the best results from this important non-pharmacological treatment. n
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37. Sticherling C, Available at:
www.clinicaltrial.gov/ct2/results?term=Atrioventricular+ %28AV%29+node+ablation+in+cardiac+resynchronizatio n+therapy
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