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

doi:10.1016/j.amjcard.2004.08.028

The American Journal of Cardiology

Volume 94, Issue 12, 15 December 2004, Pages 1506-1509

https://doi.org/10.1016/j.amjcard.2004.08.028 Get rights and content

Cardiac resynchronization therapy (CRT) is a new therapeutic option for patients who have drug-refractory end-stage heart failure. Much information has been obtained from patients who have sinus rhythm, but the use of CRT in patients who have chronic atrial fibrillation (AF) has not been studied extensively. Accordingly, we evaluated the clinical response and long-term survival rate of CRT in patients who had heart failure and chronic AF, and the results were compared with those in patients who had sinus rhythm and who underwent CRT. Sixty patients who had end-stage heart failure (30 had sinus rhythm and 30 had chronic AF), New York Heart Association classes III to IV, left ventricular ejection fraction <35%, QRS interval >120 ms, and a left bundle branch block received a biventricular pacemaker. New York Heart Association class, Minnesota Quality of Life score, and 6-minute walking distance were evaluated at baseline and after 6 months of CRT. Long-term follow-up was ≤2 years. New York Heart Association class, Minnesota Quality of Life score, and 6-minute walking distance improved significantly in the 2 groups after 6 months of CRT. The number of nonresponders was greater among patients who had AF. Nevertheless, the long-term survival rate was comparable between patients who had sinus rhythm and those who had AF. Patients who had AF demonstrated comparable benefit from CRT as those who had sinus rhythm.

Section snippets

Patients and study design

Based on traditional selection criteria of patients who have drug-refractory heart failure (New York Heart Association [NYHA] class III or IV, left ventricular ejection fraction <35%, QRS duration >120 ms or >200 ms for a paced QRS, and left bundle branch block configuration), 30 consecutive patients who had sinus rhythm and 30 consecutive patients who had AF underwent implantation of a CRT device. All patients who had AF had a persistent type (>3 months). All subjects are part of a prospective

Baseline characteristics

Thirty consecutive patients who had sinus rhythm and 30 consecutive patients who had AF underwent CRT and were included in the study. The study population comprised 51 men and 9 women (mean age 65 ± 9 years). Underlying etiology was nonischemic in 31 patients (52%) and ischemic in 29 patients (48%). Mean NYHA class was 3.2 ± 0.4, with most patients (80%) in NYHA class III. Medication included diuretics in all patients, angiotensin-converting enzyme inhibitors in 90%, β blockers in 50%,

Discussion

In the present study, the benefit of CRT in patients who had AF was compared with that in patients who had sinus rhythm. The main findings are that (1) benefit, as measured by clinical parameters (NYHA class, exercise capacity, and quality of life score), was comparable between patients who had sinus rhythm and those who had AF; (2) the number of nonresponders was higher among patients who had AF; (3) the decrease in hospitalization rate was comparable between patients who had AF and those who

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Cited by (198)

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.
Positive impact of pulmonary vein isolation on biventricular pacing in nonresponders to cardiac resynchronization therapy
2019, Heart Rhythm
Cardiac resynchronization therapy (CRT) is less effective in patients with atrial fibrillation (AF) because of impaired ventricular CRT capture.
We investigated the effects of catheter ablation in patients with AF and previous nonresponse to CRT.
Consecutive patients with AF and CRT nonresponse who underwent catheter ablation for AF were analyzed. CRT nonresponse was defined as one of the following: (1) reduced biventricular capture <95% due to rapidly conducted AF, (2) <1 point improvement in New York Heart Association (NYHA) class after CRT implantation, or (3) insufficient increase in left ventricular ejection fraction (LVEF; ≤5%) after CRT implantation.
Thirty-eight patients (8 women [21%]; mean age 68 ± 10 years; LVEF 30% ± 7%, biventricular capture 88.0% [25th, 75th percentile 75.3%, 98.5%]) underwent catheter ablation. One major and 1 minor complication occurred (1 lethal atrioesophageal fistula and 1 hemodynamically nonrelevant pericardial effusion). The Kaplan-Meier estimates for arrhythmia-free survival after single and multiple ablation procedures were 29% (95% confidence interval 16%–51%) and 67% (95% confidence interval 53%–86%) after 24 months. After a median follow-up of 817 days (25th, 75th percentile 179, 1741 days), biventricular capture and LVEF were significantly higher (median [25th, 75th percentile] 99% [96%, 99%], difference 8% [0.2%, 3.75%], P < .0001; mean 32.1% ± 9.1%, difference 2.2% ± 7.1%, P = .0225) and patients had a significantly lower functional NYHA class (28 of 37 patients with improvement of at least 1 point; P < .0001).
Catheter ablation of AF significantly improves CRT response in patients with heart failure and concomitant AF in terms of increased biventricular capture and LVEF and improved functional NYHA class.
Role of Atrioventricular Junctional Ablation and Cardiac Resynchronization Therapy in Patients with Chronic Atrial Fibrillation
2019, Cardiac Electrophysiology Clinics
Impact on long-term cardiovascular outcomes of different cardiac resynchronization therapy response criteria
2018, Revista Portuguesa de Cardiologia
There is a lack of consensus on the definition of response to cardiac resynchronization therapy (CRT), and it is not clear which response criteria have most influence on cardiac event-free survival.
To assess the predictive value of various response criteria in patients undergoing CRT and the agreement between them.
We performed a secondary analysis of the BETTER-HF trial. Patient response was classified at six months after CRT according to eleven criteria used in previous trials. The predictive value of response criteria for survival free from mortality, cardiac transplantation and heart failure hospitalization was assessed by Cox regression analysis. Agreement between the different response criteria was assessed using Cohen's kappa (κ).
A total of 115 patients were followed for a mean of 25 months. During follow-up, 15 deaths occurred (13%) and 29 patients had at least one adverse cardiac event (25%). Only five of the eleven response criteria were predictors of event-free survival. The most powerful isolated clinical and echocardiographic predictors were a reduction of ≥1 NYHA functional class (HR 0.39 for responders; 95% CI 0.18-0.83, p=0.014) and an increase of at least 15% in left ventricular ejection fraction (HR 0.43, 95% CI 0.20-0.90, p=0.024), respectively. Agreement between the different response criteria was poor.
Most currently used response criteria do not predict clinical outcomes and have poor agreement. It is essential to establish a consensus on the definition of CRT response in order to standardize studies.
Não existe consenso na definição de respondedor à ressincronização cardíaca (TRC), e desconhece-se qual o critério de resposta que poderá ter maior influência na sobrevida livre de eventos cardíacos.
Avaliar o valor preditivo de vários critérios de resposta em doentes submetidos à TRC, e analisar a concordância entre eles.
Subanálise do ensaio BETTER-HF. Os doentes foram classificados aos seis meses após TRC em respondedores, de acordo com onze critérios utilizados na literatura. O valor preditivo dos diferentes critérios de resposta para uma sobrevida livre de morte, transplante cardíaco e hospitalização por insuficiência cardíaca foi avaliado usando a regressão de Cox. A concordância entre os diferentes critérios foi avaliada usando o coeficiente k de Cohen.
115 doentes foram seguidos durante um período médio de 25 meses. Durante o follow-up ocorreram 15 mortes (13%) e 29 doentes tiveram, pelo menos, um evento cardíaco adverso (25%). Apenas cinco dos onze critérios de resposta foram preditores de sobrevida livre de eventos. Os preditores clínicos e ecocardiográficos isolados mais poderosos foram a redução de, pelo menos, uma classe funcional de NYHA (HR 0,39; IC 95% 0,18-0,83, p=0,014) e um aumento de, pelo menos, 15% na fração de ejeção ventricular esquerda (FEVE) (HR 0,43; IC 95% 0,20-0,90, p=0,024), respetivamente. A concordância entre os diferentes critérios de resposta foi fraca.
A maioria dos critérios de resposta utilizados não prevê outcomes clínicos e têm fraca concordância. É essencial criar um consenso na definição de resposta à TRC de forma a uniformizar os estudos.
Utility of Frailty Assessment for Elderly Patients Undergoing Cardiac Resynchronization Therapy
2017, JACC: Clinical Electrophysiology
The aim of this study was to evaluate the impact of frailty in the elderly on response to cardiac resynchronization therapy (CRT).
CRT has been shown to improve symptoms and outcome of patients with congestive heart failure (HF) and impaired left ventricular ejection fraction (LVEF). The impact of frailty on the results of CRT is unknown.
Frailty defined as <14 of 17 points using the ONCODAGE (Outil de dépistage gériatrique en oncologie) G8 score was assessed before device implantation in candidates for CRT who were >70 years of age. The primary endpoint was the response to CRT, defined as an improvement of >5% of the LVEF and the absence of hospitalization for HF or cardiovascular death at 9 months.
Ninety-two of 151 included patients (61%) were frail, and 89 (59%) were responders. Frailty was more frequent in nonresponders: 45 of 62 (73%) versus 47 of 89 (53%) (p = 0.014) and was identified as an independent predictor of nonresponse to CRT (R = 0.30; 95% confidence interval: 0.02 to 0.59; p = 0.039). Frailty was associated with a higher cumulative probability of hospitalization for HF (log-rank p = 0.032) and of all-cause death (log-rank p = 0.033). A G8 score <10.25 correlated with hospitalization for HF or death at 9 months (area under the curve: 0.75; 95% confidence interval: 0.63 to 0.87; cutoff <10.25; 77% sensitivity, 63% specificity).
Frailty is as an independent predictor of nonresponse to CRT. Frail patients implanted with CRT devices have a higher risk of hospitalization for HF and mortality. Routine comprehensive geriatric assessment at the time of screening for device therapy should be recommended to optimize management. (Frailty Score Assessment for Elderly Patients Undergoing Cardiac Resynchronization Therapy [FRAILTY]; NCT02369419)
Continuous optimization of cardiac resynchronization therapy reduces atrial fibrillation in heart failure patients: Results of the Adaptive Cardiac Resynchronization Therapy Trial
2017, Heart Rhythm
Citation Excerpt :
However, the effect of CRT on AF is less clear. Many observational studies have suggested that CRT reduces the risk of AF.11–16 Yet, data from 3 large clinical trials have shown conflicting results; 1 study found no benefit,17 another found benefit only in patients with significant left atrial (LA) remodeling,18 and a third found a trend toward an increased incidence of AF.19
Data from randomized trials have suggested a modest or no effect of conventional cardiac resynchronization therapy (convCRT) on the incidence of atrial fibrillation (AF). AdaptivCRT (aCRT, Medtronic, Mounds View, MN) is a recently described algorithm for synchronized left ventricular (LV) pacing and continuous optimization of cardiac resynchronization therapy (CRT).
We compared the long-term effects of aCRT with convCRT pacing on the incidence of AF.
The Adaptive CRT trial randomized CRT-defibrillator (CRT-D)–indicated patients (2:1) to receive either aCRT or convCRT pacing. The aCRT algorithm evaluates intrinsic conduction every minute, providing LV-only pacing during normal atrioventricular (AV) conduction and AV and ventriculoventricular timing adjustments during prolonged AV conduction. The primary outcome of this subanalysis was an episode of AF >48 consecutive hours as detected by device diagnostics.
Over a follow-up period with a mean and standard deviation of 20.2 ± 5.9 months, 8.7% of patients with aCRT and 16.2% with convCRT experienced the primary outcome (hazard ratio [HR] = 0.54; 95% confidence interval [CI] = 0.31–0.93; P = .03). In patients with prolonged baseline AV, the incidence of the primary outcome was 12.8% in patients randomized to aCRT compared with 27.4% in convCRT patients (HR = 0.45; 95% CI = 0.24–0.85; P = .01). Also, patients with AF episodes adjudicated as clinical adverse events were less common with aCRT (4.3%) than with convCRT (12.7%) (HR = 0.39; 95% CI = 0.19–0.79; P = .01).
Patients receiving aCRT had a reduced risk of AF compared with those receiving convCRT. Most of the reduction in AF occurred in subgroups with prolonged AV conduction at baseline and with significant left atrial reverse remodeling.

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: Dr. Molhoek received grant 2001D015, and Dr. Bleeker received grant 2002B109 from the Dutch Heart Foundation, The Hague, and the Interuniversity Cardiology Institute of Netherlands, Utrecht, The Netherlands.

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

Section snippets

Patients and study design

Baseline characteristics

Discussion

Lancet

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol