Outcomes of cardiac resynchronisation therapy in patients with heart failure with atrial fibrillation: a systematic review and meta-analysis of observational studies

Abstract

BackgroundCardiac resynchronisation therapy (CRT) is beneficial in selected patients with heart failure (HF) in normal sinus rhythm (NSR). We sought to evaluate the impact of CRT with or without atrioventricular junction (AVJ) ablation in patients with HF with concomitant atrial fibrillation (AF)Methods and resultsLiterature was searched (inception through 30 August 2017) for observational studies that reported outcomes in patients with HF with CRT and AF that reported all-cause and cardiovascular mortality. Thirty-one studies with 83, 571 patients were included. CRT did not decrease mortality compared with internal cardioverter defibrillator or medical therapy alone in patients with HF and AF with indications for CRT (OR: 0.851, 95% CI 0.616 to 1.176, p=0.328, I2=86.954). CRT-AF patients had significantly higher all-cause and cardiovascular mortality than CRT-NSR patients ([OR: 1.472, 95% CI 1.301 to 1.664, p=0.000] and [OR: 1.857, 95% CI 1.350 to 2.554, p=0.000] respectively). Change in left ventricular ejection fraction was not different between CRT patients with and without AF (p=0.705). AVJ ablation, however, improved all-cause mortality in CRT-AF patients when compared with CRT-AF patients without AVJ ablation (OR: 0.485, 95% CI 0.247 to 0.952, p=0.035). With AVJ ablation, there was no difference in all-cause mortality in CRT-AF patients compared with CRT-NSR patients (OR: 1.245, 95% CI 0.914 to 1.696, p=0.165).ConclusionThe results of our meta-analysis suggest that AF was associated with decreased CRT benefits in patients with HF. CRT, however, benefits patients with AF with AVJ ablation.

A prognostic nomogram for event-free survival in patients with atrial fibrillation before cardiac resynchronization therapy

“…Interestingly, the type of AF was not associated with the prediction of composite endpoint of HF patients, possibly due to benefits from optimal drug treatments after discharge and a high percentage of biventricular pacing (BIVP, median > = 98%), which was consistent with previous conclusions [15,32]. Even though much data have recommended AVJA for patients undergoing CRT in persistent or permanent AF to ensure better BIVP and prognosis, few studies have explored the effects of paroxysmal AF on long-term prognosis [11]. One study indicated that paroxysmal AF increased the risk of mortality by 32% after adjustment for age, sex, BIVP% and shock treatment of CRT-D compared with 51 and 28% in persistent and permanent AF, respectively [32].…”

“…However, the efficacy of CRT in patients with atrial fibrillation (AF) still remains a knowledge gap, although the concurrence of AF and HF is common in clinical practice, ranging from < 5% in asymptomatic HF patients to nearly 50% in symptomatic HF patients [4]. Several studies have supported the benefits of CRT in AF patients [5][6][7][8], though compared with those in sinus rhythm, AF was also associated with a higher risk of mortality in CRT candidates [9][10][11]. Unfortunately, there are currently no predictive models proposed in clinical practice for AF patients undergoing CRT that can stratify patients by risk and evaluate their long-term prognosis.…”

Impact of QRS morphology on response to conduction system pacing after atrioventricular junction ablation

“…Atrioventricular junction ablation is performed in patients with symptomatic, drug‐refractory, long‐standing persistent AF as part of an ‘ablate and pace’ strategy 6 . The APAF‐CRT and other studies have demonstrated that BVP combined with AVJ ablation can be the mainstay of pacing and ablation therapy in patients who have decreased ejection fraction or clinical heart failure by reducing the negative haemodynamic effects of right ventricular apical pacing and underlying rapid AF 15,16 . The benefits of BVP are limited by non‐responders and patients with suboptimal clinical outcomes, which may in part be due to the fact that BVP does not completely reverse electrical dyssynchrony, but rather decreases its magnitude, limiting its application, especially in patients with narrow QRS duration or non‐LBBB 5 .…”

Atrial fibrillation in cardiac resynchronization therapy

“…A more recent meta-analysis of observational studies, which included 83,571 patients, also demonstrated a significantly higher mortality rate after CRT implant in patients with AF, compared to those in sinus rhythm. 9 In addition, patients with heart failure and AF were not found to have a significant reduction in mortality or in a composite endpoint of mortality or heart failure hospitalization after CRT, when compared to either ICD or medical therapy. Importantly, in the sub-group of patients with AF who received an AV node ablation, mortality was significantly lower, and equivalent to patients with sinus rhythm, as discussed later in this article.…”

“…6,7 AF appears to attenuate the response to CRT, and patients with AF have a higher longterm mortality after CRT implant compared to those in sinus rhythm. 8,9 The delivery of CRT may also alter the natural progression of AF in patients with heart failure. In this article we review the evidence for CRT in patient with AF, explore the relationship between AF and CRT delivery, and discuss the treatment options available in this patient cohort.…”