A randomized controlled trial of atrioventricular junction ablation and cardiac resynchronization therapy in patients with permanent atrial fibrillation and narrow QRS
Key result
AV junction ablation plus CRT cuts major HF events ~62% versus pharmacological rate control.
- HR 0.38
- 95% CI 0.18-0.81
- P=0.013
- n=102
Why the study?
It was hypothesized that AV junction ablation combined with CRT is superior to pharmacological rate-control therapy in reducing HF and hospitalization in patients with permanent AF and narrow QRS.
Does atrioventricular junction ablation and cardiac resynchronization therapy reduce the composite of heart failure death, hospitalization, or worsening heart failure in patients with permanent atrial fibrillation, narrow QRS, and prior heart failure hospitalization?
Population
102 patients with severely symptomatic permanent AF, narrow QRS, and prior HF hospitalization
Comparison
AV junction ablation and CRT vs pharmacological rate-control therapy
Design
Randomized controlled trial
Follow-up
Median 16 months
Authors
Discussion
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Member takes
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“We hypothesise that the observed benefit was due to the combination of the strict rate control and rate regularisation achieved by AV junction ablation, together with biventricular pacing which counteracted the adverse effects of right ventricular pacing. The improvement in survival shown by the APAF-CRT trial supports ablation plus CRT as a first line therapy in patients with permanent AF, narrow QRS and previous hospitalisation for heart failure.”
MGMichael GliksonCardiologist, Shaare Zedek Medical Center, Jerusalem
“The trial makes an important contribution to establishment of AV nodal ablation with CRT as first-line therapy of resistant atrial fibrillation with congestive heart failure, mostly in patients with reduced ejection fraction. The jury is still out regarding the advantage of CRT over RV apical pacing in AV nodal ablation patients with normal or near-normal ejection fraction, and the role of conduction-system pacing remains to be established.”
“The benefit was due to the combination of the strict rate control and rate regularization achieved by AV junction ablation together with biventricular pacing, which counteracted the adverse effects of right ventricular pacing.”
Implication
May warrant AV junction ablation plus CRT over rate control now; first RCT evidence, challenging drugs alone and extending CRT to narrow QRS.
Key Points
- To determine whether atrioventricular junction ablation combined with cardiac resynchronization therapy is superior to pharmacological rate-control therapy in reducing heart failure progression and hospitalization in patients with permanent atrial fibrillation and narrow QRS.
- Randomized controlled trial (NCT02137187) enrolling 102 patients (mean age 72 ± 10 years) with permanent atrial fibrillation (>6 months), narrow QRS (≤110 ms), and a prior heart failure hospitalization in the preceding year.
- Participants were randomly allocated to receive either atrioventricular junction ablation combined with cardiac resynchronization therapy or pharmacological rate-control therapy, with defibrillators implanted per clinical guidelines and a median follow-up of 16 months.
- The primary composite endpoint of heart failure death, heart failure hospitalization, or worsening heart failure occurred in 20% (10/50) of the Ablation+CRT arm versus 38% (20/52) of the Drug arm (HR 0.38; 95% CI 0.18–0.81; P = 0.013).
- Patients receiving Ablation+CRT had significantly lower rates of all-cause death or heart failure hospitalization (12% vs. 33%; HR 0.28; 95% CI 0.11–0.72; P = 0.008) and heart failure hospitalization alone (10% vs. 25%; HR 0.30; 95% CI 0.11–0.78; P = 0.024).
- Ablation+CRT achieved a 36% relative reduction in specific atrial fibrillation symptoms and physical limitations compared to drug therapy at 1-year follow-up (P = 0.004).
Study Design
Type
RCT (n=102)
Randomization
randomly assigned
Structured PICO
Does atrioventricular junction ablation and cardiac resynchronization therapy reduce the composite of heart failure death, hospitalization, or worsening heart failure in patients with permanent atrial fibrillation, narrow QRS, and prior heart failure hospitalization?
P
Population
102 patients (mean age 72 years) with severely symptomatic permanent AF, narrow QRS, and prior HF hospitalization, followed for a median of 16 months.
I
Intervention
Atrioventricular (AV) junction ablation and cardiac resynchronization therapy (CRT) (plus defibrillator according to guidelines).
C
Comparator
Pharmacological rate-control therapy (plus defibrillator according to guidelines).
O
Outcome
Composite outcome of death due to heart failure, hospitalization due to heart failure, or worsening heart failure at median 16 months follow-up.composite
Main Result
Hazard Ratio: 0.38 (95% CI 0.18–0.81)
Absolute Event Rate: 20% vs 38%
p-value: p=0.013
Atrioventricular junction ablation combined with cardiac resynchronization therapy significantly reduces heart failure events and hospitalizations compared to pharmacological rate control in elderly patients with permanent atrial fibrillation and narrow QRS.
Cite This Study
Brignole et al. (2018) conducted an RCT in permanent atrial fibrillation and narrow QRS (n=102). atrioventricular junction ablation and cardiac resynchronization therapy vs. pharmacological rate-control therapy was evaluated on composite outcome of death due to HF, or hospitalization due to HF, or worsening HF (HR 0.38, 95% CI 0.18-0.81, p=0.013). AV junction ablation and CRT was superior to pharmacological rate-control therapy in reducing the composite of HF death, HF hospitalization, or worsening HF (HR 0.38; 95% CI 0.18-0.81; P=0.013).