The Benefit of Atrioventricular Junction Ablation for Permanent Atrial Fibrillation and Heart Failure Patients Receiving Cardiac Resynchronization Therapy: An Updated Systematic Review and Meta-analysis

Yoga Waranugraha, Ardian Rizal, Dion Setiawan, Indra Jabbar Aziz, Yoga Waranugraha, Ardian Rizal, Dion Setiawan, Indra Jabbar Aziz

Abstract

Background: Atrial fibrillation (AF) is correlated with a poor biventricular pacing and inadequate response to cardiac resynchronization therapy (CRT). Biventricular pacing improvement can be achieved by conducting the atrioventricular junction ablation (AVJA). We aimed to investigate the benefit of AVJA for permanent AF and heart failure with reduced ejection fraction (HFrEF) patients receiving CRT.

Methods: In August 2020, a systematic review and meta-analysis study comparing CRT plus AVJA versus CRT for permanent AF and HFrEF patients was conducted. Relevant articles were identified through the electronic scientific database such as ClinicalTrials.gov, ProQuest, ScienceDirect, PubMed, and Cochrane. The pooled risk ratio (RR) and pooled mean difference (MD) were estimated.

Results: A total of 3199 patients from 14 cohort studies were involved in this study. Additional AVJA reduced cardiovascular mortality (RR = 0.75, 95% confidence interval [CI] = 0.61 to 0.93, P < 0.01) in permanent AF and HFrEF patients receiving CRT. Biventricular pacing rate was higher in CRT plus AVJA group (MD = 8.65%, 95% CI = 5.62 to 11.67, P < 0.01) than in CRT alone group. The reverse remodeling characterized by the reduction of left ventricular end-diastolic diameter (LVEDD) was greater in the CRT plus AVJA group (MD = -2.11 mm, 95% CI = -3.79 to -0.42, P = 0.01).

Conclusion: In permanent AF and HFrEF patients receiving CRT, AVJA effectively increased the biventricular pacing rate. Adequate biventricular pacing rate provided a better response to the CRT marked by the greater ventricular reverse remodeling and survival from cardiovascular mortality.

Keywords: Atrioventricular junction ablation; Cardiac resynchronization therapy; Heart failure; Permanent atrial fibrillation.

Conflict of interest statement

Declaration of competing interest All authors declare that there is no conflict of interest regarding the publication of this manuscript.

Copyright © 2021 Indian Heart Rhythm Society. Production and hosting by Elsevier B.V. All rights reserved.

Figures

Fig. 1
Fig. 1
Flowchart of the study selection process.
Fig. 2
Fig. 2
Forest plot of primary outcomes: (A) all-cause mortality; (B) cardiovascular mortality; and (C) heart failure rehospitalization. AVJA = atrioventricular junction ablation; CI = confidence interval; CRT = cardiac resynchronization therapy; M-H = Mantel-Haenszel.
Fig. 3
Fig. 3
Forest plot of secondary outcomes: (A) biventricular pacing rate; (B) improvement of left ventricular ejection fraction; and (C) reduction of left ventricular end diastolic diameter. AVJA = atrioventricular junction ablation; CI = confidence interval; CRT = cardiac resynchronization therapy; IV = inverse variance; SD = standard deviation.
Fig. 4
Fig. 4
Forest plot of secondary outcomes: (A) improvement of New York Heart Association functional class; (B) improvement of walking distance in six-minute walk test; and (C) improvement of Minnesota living with heart failure questionnaire. AVJA = atrioventricular junction ablation; CI = confidence interval; CRT = cardiac resynchronization therapy; IV = inverse variance; SD = standard deviation.
Fig. 5
Fig. 5
Funnel plot analysis showing asymmetrical funnel plot for all-cause mortality.

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