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European Heart Journal Advance Access published online on April 4, 2008
European Heart Journal, doi:10.1093/eurheartj/ehn133
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Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2008. For permissions please email: journals.permissions@oxfordjournals.org
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Long-term survival in patients undergoing cardiac resynchronization therapy: the importance of atrio-ventricular junction ablation in patients with permanent atrial fibrillation

Maurizio Gasparini1,*, Angelo Auricchio2,3, Marco Metra4, François Regoli1, Cecilia Fantoni2,3, Barbara Lamp5, Antonio Curnis4, Juergen Vogt5, Catherine Klersy for the Multicentre Longitudinal Observational Study (MILOS) Group6

1 Electrophysiology and Pacing Unit, IRCCS Istituto Clinico Humanitas Rozzano-Milano, Via Manzoni 56, Rozzano, Milano IT-2089, Italy
2 Department of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland
3 Division of Cardiology, University Hospital Magdeburg, Magdeburg, Germany
4 Section of Cardiovascular Diseases, Department of Experimental and Applied Medicine, Unit of Cardiology, University and Spedali Civili, Brescia, Italy
5 Department of Cardiology, Heart and Diabetes Centre NRW, Bad Oeynhausen, Germany
6 Service of Biometry and Clinical Epidemiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy

Received 24 June 2007; revised 1 February 2008; accepted 10 March 2008.

* Corresponding author. Tel: +39 0282244622, Fax: +39 0282244693, Email: maurizio.gasparini{at}humanitas.it

Aims: To investigate the effects of cardiac resynchronization therapy (CRT) on survival in heart failure (HF) patients with permanent atrial fibrillation (AF) and the role of atrio-ventricular junction (AVJ) ablation in these patients.

Methods and results: Data from 1285 consecutive patients implanted with CRT devices are presented: 1042 patients were in sinus rhythm (SR) and 243 (19%) in AF. Rate control in AF was achieved by either ablating the AVJ in 118 patients (AVJ-abl) or prescribing negative chronotropic drugs (AF-Drugs). Compared with SR, patients with AF were significantly older, more likely to be non-ischaemic, with higher ejection fraction, shorter QRS duration, and less often received ICD back-up. During a median follow-up of 34 months, 170/1042 patients in SR and 39/243 in AF died (mortality: 8.4 and 8.9 per 100 person-year, respectively). Adjusted hazard ratios were similar for all-cause and cardiac mortality [0.9 (0.57–1.42), P = 0.64 and 1.00 (0.60–1.66) P = 0.99, respectively]. Among AF patients, only 11/118 AVJ-abl patients died vs. 28/125 AF-Drugs patients (mortality: 4.3 and 15.2 per 100 person-year, respectively, P < 0.001). Adjusted hazard ratios of AVJ-abl vs. AF-Drugs was 0.26 [95% confidence interval (CI) 0.09–0.73, P = 0.010] for all-cause mortality, 0.31 (95% CI 0.10–0.99, P = 0.048) for cardiac mortality, and 0.15 (95% CI 0.03–0.70, P = 0.016) for HF mortality.

Conclusion: Patients with HF and AF treated with CRT have similar mortality compared with patients in SR. In AF, AVJ ablation in addition to CRT significantly improves overall survival compared with CRT alone, primarily by reducing HF death.

Key Words: Cardiac resynchronization therapy • Heart failure • Atrial fibrillation • Atrio-ventricular junction ablation


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