Comparison of Benefits and Mortality in Cardiac Resynchronization Therapy in Patients With Atrial Fibrillation Versus Patients in Sinus Rhythm (Results of the Spanish Atrial Fibrillation and Resynchronization [SPARE] Study)

doi:10.1016/j.amjcard.2008.04.008

The American Journal of Cardiology

Volume 102, Issue 4, 15 August 2008, Pages 444-449

https://doi.org/10.1016/j.amjcard.2008.04.008 Get rights and content

The efficacy of cardiac resynchronization therapy (CRT) in patients with atrial fibrillation (AF) and the need for atrioventricular junction ablation in these patients is controversial. The aim of the study was to analyze CRT results in patients with permanent AF. A total of 470 consecutive patients who underwent CRT in 6 centers were included in this study. Of these patients, 126 (27%) had permanent AF. Patients were evaluated at baseline and 12 months. No difference was found in the magnitude of improvement experienced by patients with AF compared with those in sinus rhythm (SR) with respect to quality of life, distance in 6-minute walking test, and left ventricular reverse remodeling. Despite the beneficial effects of CRT, death from refractory heart failure at 12 months was higher in patients with AF (17 of 126; 13.5%) than those in SR (14/344; 4.1%; p <0,001). Furthermore, permanent AF was an independent predictive factor for mortality from refractory heart failure (hazard ratio 5.4, 95% confidence interval 1.9 to 15.1). In conclusion, patients with AF treated with CRT who survived at the 12-month follow-up had the same functional improvement and remodeling as those in SR. However, AF was an independent risk factor for mortality from heart failure after CRT implantation.

Section snippets

Methods

A cohort of 470 consecutive patients who received a CRT device from January 2000 to October 2005 was included in this national retrospective multicenter study. Inclusion criteria were symptomatic heart failure (New York Heart Association [NYHA] class ≥III) despite optimal drug therapy, with left ventricular ejection fraction ≤35% and QRS duration >120 ms, and patients in NYHA class ≥II with left ventricular ejection fraction ≤35% who received a defibrillator or pacemaker and needed permanent

Results

Of 470 consecutive patients who were treated with CRT, 126 (27%) had permanent AF. The cumulative percentage of ventricular pacing in the AF group was 94 ± 8% at 12 months. Basal characteristics of the 2 groups (AF vs SR) were listed in Table 1. Patients with AF were older and had worse NYHA functional class. The percentage of implantable cardioverter-defibrillators implanted in patients with AF was lower than in those in SR, probably because of older age. Results of the 6-minute walking

Discussion

Although the benefit of CRT in patients with wide QRS and refractory heart failure has been extensively evaluated, data for patients with AF were scarce and came mainly from nonrandomized or small studies.3, 4, 5, 6, 7 A recent study published by Gasparini et al⁶ suggested that the benefit of CRT in patients with permanent AF was restricted to those undergoing atrioventricular node ablation. To our knowledge, our study was the largest series to show a clear benefit of CRT in patients with AF

Acknowledgments

Vidal B, MD (Hospital Clinic Barcelona); Delgado V, MD (Hospital Clinic Barcelona); Godoy M, MD (Hospital Clinic Barcelona); Toquero J, MD (Puerta de Hierro Madrid); Castaño S, MD (Clínica Universitaria de Navarra); Payá R, MD (Hospital General de Valencia); Jimenez J, MD (Hospital General de Valencia); Palanca V, MD (Hospital General de Valencia); Pérez JL, MD (Hospital General de Valencia); Moya JL, MD (Hospital Universitario Ramón y Cajal Madrid).

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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
2021, Indian Pacing and Electrophysiology Journal
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.
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.
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).
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.
Atrial Fibrillation Ablation Should Be First-Line Therapy in Heart Failure Patients: CON
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Device pacing diagnostics overestimate effective cardiac resynchronization therapy pacing results of the hOLter for Efficacy analysis of CRT (OLÉ CRT) study
2017, Heart Rhythm
A high percentage of biventricular (BiV) or left ventricular (LV) pacing in cardiac resynchronization therapy (CRT) devices has been associated with superior clinical outcomes. However, the percent ventricular (%V) pacing reported by CRT devices simply indicates the number of paces the device has delivered and not the proportion of pacing that has captured the LV effectively.
The purpose of this study was to determine whether a beat-by-beat evaluation of effective pacing would provide a more accurate evaluation of CRT delivery.
An automatic electrogram (EGM)-based algorithm that classifies each LV pace as effective or ineffective based on detection of QS/QS-r morphology on the unipolar LV EGM during pacing was developed and validated. LV EGMs that were recorded by 24-hour Holter from 57 CRT patients were postprocessed. The percent effective CRT (%e-CRT) pacing was calculated by dividing the time spent in e-CRT pacing by the total time of the recording.
In this CRT cohort, the average %V pacing (94.8% ± 8%) significantly overestimated the %e-CRT pacing (87.5% ± 23%; P <.001). A significant minority of subjects (18%) had a discrepancy of at least 3 percentage points between %V pacing and %e-CRT pacing (mean 39% ± 41%).
Current device pacing diagnostics overestimate the amount of CRT pacing actually delivered. The new algorithm quantifies ineffective CRT pacing, which enables clinicians to identify patients with this issue and to address the reasons behind suboptimal CRT delivery.
Adverse Impact of Delayed Electrical Activation of the Heart and Benefits of Cardiac Resynchronization
2017, Encyclopedia of Cardiovascular Research and Medicine
Delayed electrical conduction, represented as a wide QRS native conduction, occurs often in patients with heart failure (HF), and this activation delay causes adverse hemodynamics leading to decrease of left ventricular ejection fraction (LVEF). Biventricular pacing is utilized to provide cardiac resynchronization therapy (CRT) and to help alleviate HF symptoms in patients with decreased LVEF and wide QRS complex. This article provides an overview of the adverse hemodynamics of a prolonged QRS complex, reverse remodeling by CRT, evolution in lead placement, and a detailed review of clinical trials and outcomes over the past two decades. Additionally, the most recent patient selection criteria are reviewed and how evidence-based medicine has transpired into current guideline recommendations for CRT. Finally, there is a discussion regarding management of nonresponse to CRT and new device technology.
Atrial Fibrillation During Cardiac Resynchronization Therapy
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: This study was supported by a grant awarded by the Spanish Society of Cardiology, Madrid, Spain, in 2006 and a Thematic Networks in Health Cooperative Research grant (REDSINCOR RD 06/0003/008) from the Spanish Health Ministry, Madrid, Spain, and partially funded by Medtronic, Inc, Madrid, Spain.

View full text

Arrhythmias and conduction disturbanceComparison of Benefits and Mortality in Cardiac Resynchronization Therapy in Patients With Atrial Fibrillation Versus Patients in Sinus Rhythm (Results of the Spanish Atrial Fibrillation and Resynchronization [SPARE] Study)

Section snippets

Methods

Results

Discussion

Acknowledgments

Predictors of lack of response to resynchronization therapy

Am J Cardiol

Relation of response to cardiac resynchronization therapy to left ventricular reverse remodeling

Am J Cardiol

Comparison of response to cardiac resynchronization therapy in patients with sinus rhythm vs chronic atrial fibrillation

Am J Cardiol

Comparative effects of permanent biventricular pacing for refractory heart failure in patients with stable sinus rhythm or chronic atrial fibrillation

Am J Cardiol

Assessment of upgrading to biventricular pacing in patients with right ventricular pacing and congestive heart failure after atrioventricular junctional ablation for chronic atrial fibrillation

Europace

Four-year efficacy of cardiac resynchronization therapy on exercise tolerance and disease progression

J Am Coll Cardiol

Cardiac resynchronization in patients with congestive heart failure and chronic atrial fibrillation

J Am Coll Cardiol

Comparision of usefulness of cardiac resynchronization therapy in patients with atrial fibrillation and heart failure versus patients with sinus rhythm and heart failure

Am J Cardiol

Arrhythmias and conduction disturbance
Comparison of Benefits and Mortality in Cardiac Resynchronization Therapy in Patients With Atrial Fibrillation Versus Patients in Sinus Rhythm (Results of the Spanish Atrial Fibrillation and Resynchronization [SPARE] Study)