Clinical Research
Heart Rhythm Disorders
Role of AV Nodal Ablation in Cardiac Resynchronization in Patients With Coexistent Atrial Fibrillation and Heart Failure: A Systematic Review

https://doi.org/10.1016/j.jacc.2011.10.891Get rights and content
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Objectives

The aim of this study was to systematically review the medical literature to evaluate the impact of AV nodal ablation in patients with heart failure and coexistent atrial fibrillation (AF) receiving cardiac resynchronization therapy (CRT).

Background

CRT has a substantial evidence base in patients in sinus rhythm with significant systolic dysfunction, symptomatic heart failure, and prolonged QRS duration. The role of CRT is less well established in AF patients with coexistent heart failure. AV nodal ablation has recently been suggested to improve outcomes in this group.

Methods

Electronic databases and reference lists through September 15, 2010, were searched. Two reviewers independently evaluated citation titles, abstracts, and articles. Studies reporting the outcomes after AV nodal ablation in patients with AF undergoing CRT for symptomatic heart failure and left ventricular dyssynchrony were selected. Data were extracted from 6 studies, including 768 CRT-AF patients, composed of 339 patients who underwent AV nodal ablation and 429 treated with medical therapy aimed at rate control alone.

Results

AV nodal ablation in CRT-AF patients was associated with significant reductions in all-cause mortality (risk ratio: 0.42 [95% confidence interval: 0.26 to 0.68]), cardiovascular mortality (risk ratio: 0.44 [95% confidence interval: 0.24 to 0.81]), and improvement in mean New York Heart Association functional class (risk ratio: –0.52 [95% confidence interval: –0.87 to –0.17]).

Conclusions

AV nodal ablation was associated with a substantial reduction in all-cause mortality and cardiovascular mortality and with improvements in New York Heart Association functional class compared with medical therapy in CRT-AF patients. Randomized controlled trials are warranted to confirm the efficacy and safety of AV nodal ablation in this patient population.

Key Words

atrial fibrillation
biventricular pacing
cardiac resynchronization
heart failure
systematic review

Abbreviations and Acronyms

AF
atrial fibrillation
AVNA
AV nodal ablation
BVP
biventricular pacing
CI
confidence interval
CRT
cardiac resynchronization therapy
HF
heart failure
LVEF
left ventricular ejection fraction
NYHA
New York Heart Association
RR
risk ratio

Cited by (0)

Dr. Ganesan is supported by a Cardiovascular Lipid Research Grant from Pfizer Australia. Drs. Brooks, Roberts-Thomson, and Sanders are supported by the National Heart Foundation of Australia. Dr. Lau is supported by a Postdoctoral Fellowship from the National Health and Medical Research Council of Australia. Dr. Roberts-Thomson has served on the advisory board of St. Jude Medical. Dr. Sanders has received lecture fees from St. Jude Medical, Bard Electrophysiology, Biosense-Webster, Medtronic, and Merck; research funding from St. Jude Medical, Bard Electrophysiology, Biosense-Webster, and Medtronic; and is on the advisory board for St. Jude Medical, Bard Electrophysiology, Biosense-Webster, Medtronic, and Merck. Dr. Kalman has received unrestricted research grants from St. Jude Medical and Medtronic.