Abstract
Background
Whether patients with persistent atrial fibrillation (AF) obtain the same degree of
benefit with cardiac resynchronization therapy (CRT) as those in sinus rhythm remains
unclear.
Methods
We enrolled 93 patients undergoing CRT implantation, 20 (22%) of whom had rate-controlled
persistent AF. The primary endpoint was CRT response defined as 1 class improvement
in Specific Activity Scale and 15% reduction in left ventricular end-systolic volume
(LVESV) during 12 months. Other endpoints included changes in 6-minute walk distance,
quality of life, B-type natriuretic peptide, and survival.
Results
Baseline characteristics were similar in those with and without AF. Response to CRT
was observed in 42% vs 54% of those with and without AF, respectively (P = 0.3). Both groups had significant improvements in 6-minute walk distance, quality
of life, and LVESV, but the improvement in LVESV was smaller in those with AF (13.7%
± 14.9% vs 27.7% ± 23.7%; P = 0.02). During 2.8 ± 1.4 years of follow-up, AF was associated with a 2.2-fold increased
risk of death or transplantation (95% confidence interval, 1.2-3.9; P = 0.01).
Conclusions
Compared with patients without rate-controlled persistent AF, those with rate-controlled
persistent AF had similar rates of clinical improvement but less left ventricular
reverse remodelling in the first year after CRT. AF was associated with a markedly
higher risk of death or transplantation in long-term follow-up. Given these findings,
randomized studies assessing CRT efficacy in those with AF are warranted.
Résumé
Introduction
Que les patients ayant une fibrillation auriculaire (FA) persistante obtiennent les
mêmes avantages par la thérapie de resynchronisation cardiaque (TRC) que ceux maintenus
en rythme sinusal demeure obscur.
Méthodes
Nous avons inscrit 93 patients ayant subi l'implantation d'un dispositif de TRC, dont
20 (22 %) ont eu une FA persistante contrôlée par la fréquence. Le critère d'évaluation
principal a été la réponse à la TRC définie comme une amélioration de la classification
dans l'échelle de l'activité spécifique et une réduction de 15 % dans le volume télésystolique
(VTS) durant 12 mois. Les autres critères d'évaluation ont inclus des changements
dans le test de marche de 6 minutes, la qualité de vie, le peptide natriurétique de
type B et la survie.
Résultats
Les caractéristiques de base ont été similaires chez les patients présentant ou non
une FA. La réponse à la TRC a été observée dans 42 % vs 54 % des patients présentant ou non une FA, respectivement (P = 0,3). Les deux groupes ont eu des améliorations importantes dans le test de marche
de 6 minutes, la qualité de vie et le VTS, mais l'amélioration du VTS a été plus petite
chez ceux présentant une FA (13,7 % ± 14,9 % vs 27,7 % ± 23,7 %; P = 0,02). Durant 2,8 ± 1,4 ans de suivi, la FA a été associée à 2,2 fois plus de risque
de décès ou de transplantation (intervalle de confiance de 95 %, 1,2-3,9; P = 0,01).
Conclusions
Comparativement aux patients ne présentant pas de FA persistante contrôlée par la
fréquence, ceux présentant une FA persistante contrôlée par la fréquence ont eu des
taux d'amélioration clinique similaires, mais moins de remodelage inverse du ventricule
gauche la première année après la TRC. La FA a été associée à un risque beaucoup plus
marqué de décès ou de transplantation durant le suivi à long terme. En raison de ces
découvertes, les études aléatoires évaluant l'efficacité de la TRC chez les patients
présentant une FA sont justifiées.
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References
- Cardiac resynchronization therapy: a meta-analysis of randomized controlled trials.CMAJ. 2011; 183: 421-429
- The European cardiac resynchronization therapy survey.Eur Heart J. 2009; 30: 2450-2460
- Temporal relations of atrial fibrillation and congestive heart failure and their joint influence on mortality: the Framingham Heart Study.Circulation. 2003; 107: 2920-2925
- Heart failure decompensation and all-cause mortality in relation to percent biventricular pacing in patients with heart failure: is a goal of 100% biventricular pacing necessary?.J Am Coll Cardiol. 2009; 53: 355-360
- The utility of 12-lead Holter monitoring in patients with permanent atrial fibrillation for the identification of nonresponders after cardiac resynchronization therapy.J Am Coll Cardiol. 2009; 53: 1050-1055
- Cardiac-resynchronization therapy for mild-to-moderate heart failure.N Engl J Med. 2010; 363: 2385-2395
- Comparison of response to cardiac resynchronization therapy in patients with sinus rhythm versus chronic atrial fibrillation.Am J Cardiol. 2004; 94: 1506-1509
- Comparison of usefulness of cardiac resynchronization therapy in patients with atrial fibrillation and heart failure versus patients with sinus rhythm and heart failure.Am J Cardiol. 2007; 99: 1252-1257
- Long-term survival in patients undergoing cardiac resynchronization therapy: the importance of performing atrio-ventricular junction ablation in patients with permanent atrial fibrillation.Eur Heart J. 2008; 29: 1644-1652
- Long-term effects of cardiac resynchronisation therapy in patients with atrial fibrillation.Heart. 2008; 94: 879-883
- 2010 focused update of ESC guidelines on device therapy in heart failure: an update of the 2008 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure and the 2007 ESC guidelines for cardiac and resynchronization therapy.Eur Heart J. 2010; 31: 2677-2687
- ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices): developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons.Circulation. 2008; 117: e350-e408
- Canadian Cardiovascular Society Consensus Conference guidelines on heart failure, update 2009: diagnosis and management of right-sided heart failure, myocarditis, device therapy and recent important clinical trials.Can J Cardiol. 2009; 25: 85-105
- Tissue Doppler imaging is superior to strain rate imaging and postsystolic shortening on the prediction of reverse remodeling in both ischemic and nonischemic heart failure after cardiac resynchronization therapy.Circulation. 2004; 110 ([see comment]): 66-73
- AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram, part III: intraventricular conduction disturbances.J Am Coll Cardiol. 2009; 53: 976-981
- Comparative reproducibility and validity of systems for assessing cardiovascular functional class: advantages of a new specific activity scale.Circulation. 1981; 64: 1227-1234
- A review of quality-of-life evaluations in patients with congestive heart failure.Pharmacoeconomics. 1999; 16: 247-271
- Measurement of ventricular function by ECG gating during atrial fibrillation.J Nucl Med. 1981; 22: 226-231
- Cardiac resynchronization in chronic heart failure.N Engl J Med. 2002; 346: 1845-1853
- Statistics notes: the use of transformation when comparing two means.BMJ. 1996; 312: 1153
- Predicting the long-term effects of cardiac resynchronization therapy on mortality from baseline variables and the early response: a report from the CARE-HF (Cardiac Resynchronization in Heart Failure) trial.J Am Coll Cardiol. 2008; 52: 438-445
- Four-year efficacy of cardiac resynchronization therapy on exercise tolerance and disease progression: the importance of performing atrioventricular junction ablation in patients with atrial fibrillation.J Am Coll Cardiol. 2006; 48: 734-743
- Comparison of usefulness of cardiac resynchronization therapy in patients with atrial fibrillation and heart failure versus patients with sinus rhythm and heart failure.Am J Cardiol. 2007; 99: 1252-1257
- Estimation of maximum oxygen uptake from clinical data: performance of the Specific Activity Scale.Am Heart J. 1988; 115: 203-204
- Validity and reliability of the NYHA classes for measuring research outcomes in patients with cardiac disease.Heart Lung. 2002; 31: 262-270
- Long-term prognosis after cardiac resynchronization therapy is related to the extent of left ventricular reverse remodeling at midterm follow-up.J Am Coll Cardiol. 2009; 53: 483-490
- Agreement is poor among current criteria used to define response to cardiac resynchronization therapy.Circulation. 2010; 121: 1985-1991
- Prediction of response to cardiac resynchronization therapy: the Selection of Candidates for CRT (SCART) study.Pacing Clin Electrophysiol. 2006; 29: S11-S19
- Influence of the preimplantation QRS axis on responses to cardiac resynchronization therapy.Rev Esp Cardiol. 2008; 61 ([see comment]): 1245-1252
- Evaluation of left ventricular based pacing in patients with congestive heart failure and atrial fibrillation.Am J Cardiol. 1999; 83: 1138-1140
- Comparative effects of permanent biventricular pacing for refractory heart failure in patients with stable sinus rhythm or chronic atrial fibrillation.Am J Cardiol. 2000; 85: 1154-1156
- Cardiac resynchronization in patients with congestive heart failure and chronic atrial fibrillation: effect of upgrading to biventricular pacing after chronic right ventricular pacing.J Am Coll Cardiol. 2002; 39: 1258-1263
- Outcomes of cardiac resynchronization therapy in patients with versus without atrial fibrillation: a systematic review and meta-analysis.Heart Rhythm. 2011; 8: 1088-1094
Article info
Publication history
Published online: September 12, 2011
Accepted:
June 2,
2011
Received:
February 27,
2011
Footnotes
See page 792 for disclosure information.
Identification
Copyright
© 2011 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
ScienceDirect
Access this article on ScienceDirectLinked Article
- Development of Atrial Fibrillation in Recipients of Cardiac Resynchronization Therapy: The Role of Atrial Reverse RemodellingCanadian Journal of CardiologyVol. 28Issue 2
- PreviewWe congratulate Wilton et al. for their interesting report in a recent issue of the Canadian Journal of Cardiology, regarding the role of rate-controlled persistent atrial fibrillation (AF) on the clinical outcome and ventricular remodelling in patients receiving cardiac resynchronization therapy (CRT).1
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