AV junction ablation and cardiac resynchronization for patients with permanent atrial fibrillation and narrow QRS: the APAF-CRT mortality trial

Abstract

Aims In patients with atrial fibrillation (AF) and heart failure (HF), strict and regular rate control with atrioventricular junction ablation and biventricular pacemaker (Ablation + CRT) has been shown to be superior to pharmacological rate control in reducing HF hospitalizations. However, whether it also improves survival is unknown. Methods and results In this international, open-label, blinded outcome trial, we randomly assigned patients with severely symptomatic permanent AF >6 months, narrow QRS (≤110 ms) and at least one HF hospitalization in the previous year to Ablation + CRT or to pharmacological rate control. We hypothesized that Ablation + CRT is superior in reducing the primary endpoint of all-cause mortality. A total of 133 patients were randomized. The mean age was 73 ± 10 years, and 62 (47%) were females. The trial was stopped for efficacy at interim analysis after a median of 29 months of follow-up per patient. The primary endpoint occurred in 7 patients (11%) in the Ablation + CRT arm and in 20 patients (29%) in the Drug arm [hazard ratio (HR) 0.26, 95% confidence interval (CI) 0.10–0.65; P = 0.004]. The estimated death rates at 2 years were 5% and 21%, respectively; at 4 years, 14% and 41%. The benefit of Ablation + CRT of all-cause mortality was similar in patients with ejection fraction (EF) ≤35% and in those with >35%. The secondary endpoint combining all-cause mortality or HF hospitalization was significantly lower in the Ablation + CRT arm [18 (29%) vs. 36 (51%); HR 0.40, 95% CI 0.22–0.73; P = 0.002]. Conclusions Ablation + CRT was superior to pharmacological therapy in reducing mortality in patients with permanent AF and narrow QRS who were hospitalized for HF, irrespective of their baseline EF. Study registration ClinicalTrials.gov Identifier: NCT02137187.

Electrical management of heart failure: from pathophysiology to treatment

“…The results of the APAF-CRT study, which was performed in severely symptomatic patients with permanent AF and within 1 year of HF hospitalization irrespective of LVEF, showed that AV node ablation combined with CRT is preferred. 67 , 68 In this study, patients with narrow QRS complex had a 62% lower risk for the combined endpoint of mortality, HF hospitalization or worsening of HF, and a 72% lower risk of all-cause mortality and HF hospitalization in the ablate and pace group when compared with the pharmacological rate control group. Forty per cent of the study patients had LVEF ≤35%.…”

Prospective Randomized Controlled Clinical Study of Physiological Ventricular Rhythm Resetting in Patients with Atrial Fibrillation and Heart Failure: Rationale and Design

“…In current guidelines, APT is only used as the ultimate option for patients who are unresponsive or intolerant to intensive rate and rhythm control therapy [1] . We analyzed the advantages, and disadvantages of different forms of APT [9][10][11][13][14][15][16] (Table III). Studies found that regular RVAP can improve immediate hemodynamics compared with irregular RVAP of the same heart rate [9] .…”

“…APAF-CRT study compared the e cacy of AVNA with biventricular pacing therapy and medical therapy. The results showed that AVNA with biventricular pacing therapy was superior to medical therapy in reducing the incidence of HF, shortening hospitalization, improving the quality of life, and reducing allcause mortality [13,14] . This study proved the e cacy of biventricular pacing but we should not ignore its disadvantages, including high incidence of nonresponse, high operative di culty, and high cost [15][16][17] .…”

Management of Atrial Fibrillation Across the Spectrum of Heart Failure With Preserved and Reduced Ejection Fraction

“…Despite having rate-controlled permanent AF in both groups, the study showed improved functional outcomes with atrioventricular node ablation and CRT, with a potential survival advantage. 69 Given the small study size (n=133 with only 27 deaths), these results must be considered hypothesis generating, and additional confirmatory outcome studies are needed. These data do, however, support the idea that regularization of heart rate in HFrEF with AF may mediate some of the benefits of pulmonary vein isolation; using atrioventricular node ablation and CRT to achieve regularization of heart rate requires further study.…”