Long-term survival in patients undergoing cardiac resynchronization therapy: the importance of performing atrio-ventricular junction ablation in patients with permanent atrial fibrillation

Maurizio Gasparini, Angelo Auricchio, Marco Metra, François Regoli, Cecilia Fantoni, Barbara Lamp, Antonio Curnis, Juergen Vogt, Catherine Klersy, Multicentre Longitudinal Observational Study (MILOS) Group, Paola Galimberti, Carlo Ceriotti, Edoardo Gronda, Renato Bragato, Daniela Pini, Maurizio Mangiavacchi, Giosuê Mascioli, Livio dei Cas, Helga Buschler, Anja Dorszewski, Anke Schmidt, Bert Hansky, Johannes Heintze, Dieter Horstkotte, Maurizio Gasparini, Angelo Auricchio, Marco Metra, François Regoli, Cecilia Fantoni, Barbara Lamp, Antonio Curnis, Juergen Vogt, Catherine Klersy, Multicentre Longitudinal Observational Study (MILOS) Group, Paola Galimberti, Carlo Ceriotti, Edoardo Gronda, Renato Bragato, Daniela Pini, Maurizio Mangiavacchi, Giosuê Mascioli, Livio dei Cas, Helga Buschler, Anja Dorszewski, Anke Schmidt, Bert Hansky, Johannes Heintze, Dieter Horstkotte

Abstract

Aims: To investigate the effects of cardiac resynchronization therapy (CRT) on survival in heart failure (HF) patients with permanent atrial fibrillation (AF) and the role of atrio-ventricular junction (AVJ) ablation in these patients.

Methods and results: Data from 1285 consecutive patients implanted with CRT devices are presented: 1042 patients were in sinus rhythm (SR) and 243 (19%) in AF. Rate control in AF was achieved by either ablating the AVJ in 118 patients (AVJ-abl) or prescribing negative chronotropic drugs (AF-Drugs). Compared with SR, patients with AF were significantly older, more likely to be non-ischaemic, with higher ejection fraction, shorter QRS duration, and less often received ICD back-up. During a median follow-up of 34 months, 170/1042 patients in SR and 39/243 in AF died (mortality: 8.4 and 8.9 per 100 person-year, respectively). Adjusted hazard ratios were similar for all-cause and cardiac mortality [0.9 (0.57-1.42), P = 0.64 and 1.00 (0.60-1.66) P = 0.99, respectively]. Among AF patients, only 11/118 AVJ-abl patients died vs. 28/125 AF-Drugs patients (mortality: 4.3 and 15.2 per 100 person-year, respectively, P < 0.001). Adjusted hazard ratios of AVJ-abl vs. AF-Drugs was 0.26 [95% confidence interval (CI) 0.09-0.73, P = 0.010] for all-cause mortality, 0.31 (95% CI 0.10-0.99, P = 0.048) for cardiac mortality, and 0.15 (95% CI 0.03-0.70, P = 0.016) for HF mortality.

Conclusion: Patients with HF and AF treated with CRT have similar mortality compared with patients in SR. In AF, AVJ ablation in addition to CRT significantly improves overall survival compared with CRT alone, primarily by reducing HF death.

Figures

Figure 1
Figure 1
Comparison of Kaplan–Meier estimates of overall (A), cardiac (B), and heart failure (C) survival between sinus rhythm and the global atrial fibrillation population. The P-values presented derive from the adjusted hazards ratio analysis stratified according to the corresponding cause of death.
Figure 2
Figure 2
Comparison of Kaplan–Meier estimates of overall (A), cardiac (B), and heart failure (C) survival between atrial fibrillation patients who underwent atrio-ventricular junction ablation (AVJ-abl) and atrial fibrillation patients treated only with negative chronotropic drugs (AF-Drugs). The P-values presented derive from the adjusted hazards ratio analysis stratified according to the corresponding cause of death.
Figure 3
Figure 3
Hazard ratio estimates stratified according to cause of death between atrial fibrillation patients who underwent atrio-ventricular junction ablation (AVJ-abl) and atrial fibrillation patients treated with negative chronotropic drugs (AF-Drugs); hazard ratio estimates were adjusted for centre, age, gender, aetiology, NYHA class, QRS width, left ventricular ejection fraction, and device type. Corresponding hazard ratio values for each cause of death are indicated with a square, the bar represents 95% confidence interval range, and the P-value for each estimate is presented on the right of the figure.

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