AV junction ablation and cardiac resynchronization for patients with permanent atrial fibrillation and narrow QRS: the APAF-CRT mortality trial
Key result
Ablation plus CRT cuts mortality ~74% vs rate control in permanent AF with narrow QRS.
- HR 0.26
- 95% CI 0.10-0.65
- P=0.004
- n=133
Why the study?
In patients with AF and HF, AV junction ablation and biventricular pacemaker reduces HF hospitalizations compared with pharmacological rate control, but whether it improves survival was unknown.
Does atrioventricular junction ablation and biventricular pacemaker reduce all-cause mortality compared to pharmacological rate control in patients with permanent atrial fibrillation, narrow QRS, and prior heart failure hospitalization?
Key Points
- To determine whether atrioventricular junction ablation combined with biventricular pacing improves survival compared to pharmacological rate control in patients with permanent atrial fibrillation, narrow QRS, and heart failure.
- International, open-label, blinded outcome randomized trial (NCT02137187) evaluating 133 patients (mean age 73 ± 10 years, 47% female) with severely symptomatic permanent AF (>6 months), narrow QRS (≤110 ms), and recent heart failure hospitalization.
- Participants were randomly assigned to atrioventricular junction ablation combined with cardiac resynchronization therapy (Ablation + CRT) or pharmacological rate control, with a median follow-up of 29 months before early trial stoppage for efficacy.
- All-cause mortality occurred in 7 patients (11%) in the Ablation + CRT arm versus 20 patients (29%) in the drug arm (HR 0.26, 95% CI 0.10–0.65; P = 0.004).
- Estimated mortality rates were 5% vs. 21% at 2 years and 14% vs. 41% at 4 years, with consistent survival benefits observed across baseline ejection fraction strata (≤35% and >35%).
- The composite endpoint of all-cause mortality or heart failure hospitalization was significantly lower with Ablation + CRT [18 patients (29%) vs. 36 patients (51%); HR 0.40, 95% CI 0.22–0.73; P = 0.002].
Study Design
Type
RCT (n=133)
Blinding
Open-label, blinded outcome
Randomization
Randomized
Multicenter
Yes
Structured PICO
Does atrioventricular junction ablation and biventricular pacemaker reduce all-cause mortality compared to pharmacological rate control in patients with permanent atrial fibrillation, narrow QRS, and prior heart failure hospitalization?
P
Population
133 patients with severely symptomatic permanent AF >6 months, narrow QRS (≤110 ms), and prior HF hospitalization, followed for a median of 29 months.
I
Intervention
Atrioventricular junction ablation and biventricular pacemaker (Ablation + CRT)
C
Comparator
Pharmacological rate control
O
Outcome
All-cause mortalityhard clinical
Main Result
Hazard Ratio: 0.26 (95% CI 0.1–0.65)
Absolute Event Rate: 11% vs 29%
p-value: p=0.004
In patients with permanent atrial fibrillation, narrow QRS, and prior heart failure hospitalization, AV junction ablation combined with cardiac resynchronization therapy significantly reduced all-cause mortality compared to pharmacological rate control.
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“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 results are not surprising. They are in line with the prior studies with shorter follow-up, and they justify a relatively common practice today to implant CRT in these patients.”
“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 support AV-node ablation plus CRT over drugs in this high-risk group; extends prior hospitalization data to a survival benefit.
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.
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Cite This Study
Brignole et al. (2021) conducted an RCT in Permanent atrial fibrillation and heart failure (n=133). Atrioventricular junction ablation and biventricular pacemaker (Ablation + CRT) vs. Pharmacological rate control was evaluated on All-cause mortality (HR 0.26, 95% CI 0.10-0.65, p=0.004). Ablation + CRT was superior to pharmacological rate control in reducing all-cause mortality (11% vs 29%; HR 0.26; 95% CI 0.10-0.65; P=0.004) in patients with permanent AF and narrow QRS.