Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2021 Dec;8(6):5204-5212.
doi: 10.1002/ehf2.13599. Epub 2021 Sep 12.

Cardiac resynchronization therapy defibrillators in patients with permanent atrial fibrillation

Antonio Rapacciuolo  1 , Saverio Iacopino  2 , Antonio D'Onofrio  3 , Antonio Curnis  4 , Ennio C Pisanò  5 , Mauro Biffi  6 , Paolo Della Bella  7 , Antonio Dello Russo  8 , Fabrizio Caravati  9 , Gabriele Zanotto  10 , Valeria Calvi  11 , Giovanni Rovaris  12 , Gaetano Senatore  13 , Daniele Nicolis  14 , Matteo Santamaria  15 , Massimo Giammaria  16 , Giampiero Maglia  17 , Antonio Duca  18 , Giuseppe Ammirati  1 , Salvo Andrea Romano  19 , Marcello Piacenti  20 , Eduardo Celentano  21 , Giovanni Bisignani  22 , Paola Vaccaro  23 , Gennaro Miracapillo  24 , Matteo Bertini  25 , Gerardo Nigro  26 , Daniele Giacopelli  27   28 , Alessio Gargaro  27 , Caterina Bisceglia  7
Affiliations

Cardiac resynchronization therapy defibrillators in patients with permanent atrial fibrillation

Antonio Rapacciuolo et al. ESC Heart Fail. 2021 Dec.

Abstract

Aims: There are conflicting data on the benefit of cardiac resynchronization therapy (CRT) in heart failure (HF) patients with permanent atrial fibrillation (AF). We aimed to compare patient outcomes according to the presence or absence of permanent AF at device implantation.

Methods and results: We retrospectively analysed remote monitoring data from 1141 CRT defibrillators. Propensity score with inverse-probability weighting method was used to balance AF and sinus rhythm (SR) groups. Analysis endpoints included total mortality, appropriate defibrillation shocks, and CRT percentage. There were 229 patients (20.1%) in the AF group and 912 patients (79.9%) in the SR group. Compared with SR patients, AF patients were older (median age, 77 vs. 72 years, P < 0.001), more frequently male (82.5% vs. 75.5%, P = 0.02), and had higher heart rate (75.7 vs. 71.0 b.p.m., P < 0.001). Of the 229 AF patients, 162 (70.7%) received suboptimal CRT (<98%) and 67 (29.3%) had adequate CRT (≥98%). During a median follow-up of 24 months, total mortality did not differ between AF and SR groups (propensity-score-weighted hazard ratio, HR 1.32 [95% confidence interval, 0.82-2.15], P = 0.25). The risk of appropriate shocks was significantly higher in the AF group with <98% CRT than in the SR group (weighted-HR, 1.99 [1.21-3.26], P = 0.006) and was similar in the AF group with ≥98% CRT versus the SR group (1.29 [0.66-2.53], P = 0.45). During follow-up, sinus rhythm was recovered in 23 patients in the AF group (10%) after a median time of 106 (42-256) days. The rate of sinus rhythm recovery in the AF group was 4.5 (95% CI, 2.8-6.7) per 100 patient-years; the rate of permanent AF occurrence in the SR group was 2.5 (95% CI, 1.9-3.3) per 100 patient-years.

Conclusions: Although mortality was similar across patient groups, patients with permanent AF and suboptimal CRT had twofold higher risk of appropriate shocks than SR patients or AF patients with CRT ≥ 98%.

Keywords: Atrial fibrillation; Cardiac resynchronization therapy; Defibrillation shock; Heart failure; Heart rate.

PubMed Disclaimer

Conflict of interest statement

D.G. and A.G. are employees of BIOTRONIK Italia. All the remaining authors have no conflicts of interest to disclose.

Figures

Figure 1
Figure 1
Flow chart of patients included in the analysis. Median duration of follow‐up was 24 (13–42) months. AF, atrial fibrillation; CRT, cardiac resynchronization therapy; CRT‐D, CRT defibrillator; HMEA, home monitoring expert alliance.
Figure 2
Figure 2
Absolute mean differences for propensity score variables. Variables including missing values are shown before (“Unadjusted”) and after (“Adjusted”) propensity score by inverse probability of treatment weighting. ACE, angiotensin‐converting enzyme; ARBs, angiotensin II receptors blockers; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; ICM, ischaemic cardiomyopathy; LVEF, left ventricular ejection fraction; NYHA, New Your Heart Association; TIA, transient ischaemic attack; VF, ventricular fibrillation; VT, ventricular tachycardia.
Figure 3
Figure 3
Kaplan–Meier curves for all‐cause mortality and appropriate shock occurrence by study groups. AF, atrial fibrillation; HR, hazard ratio; PS, propensity score.
Figure 4
Figure 4
Kaplan–Meier curves of appropriate shock occurrence in the SR group and in the AF subgroups with suboptimal (<98%) and adequate (≥98%) CRT pacing percentage. *P = 0.006 versus SR group after PS‐weighting analysis. AF, atrial fibrillation; CRT, cardiac resynchronization therapy; PS, propensity score; SR, sinus rhythm.
See this image and copyright information in PMC

References

    1. Maisel WH, Stevenson LW. Atrial fibrillation in heart failure: epidemiology, pathophysiology, and rationale for therapy. Am J Cardiol 2003; 91: 2d–8d. - PubMed
    1. Swedberg K, Olsson LG, Charlesworth A, Cleland J, Hanrath P, Komajda M, Metra M, Torp‐Pedersen C, Poole‐Wilson P. Prognostic relevance of atrial fibrillation in patients with chronic heart failure on long‐term treatment with betablockers: results from COMET. Eur Heart J 2005; 26: 1303–1308. - PubMed
    1. Hoppe UC, Casares JM, Eiskjær H, Hagemann A, Cleland JG, Freemantle N, Erdmann E. Effect of cardiac resynchronization on the incidence of atrial fibrillation in patients with severe heart failure. Circulation 2006; 114: 18–25. - PubMed
    1. Dickstein K, Normand C, Auricchio A, Bogale N, Cleland JG, Gitt AK, Stellbrink C, Anker SD, Filippatos G, Gasparini M, Hindricks G, Blomström Lundqvist C, Ponikowski P, Ruschitzka F, Botto GL, Bulava A, Duray G, Israel C, Leclercq C, Margitfalvi P, Cano Ó, Plummer C, Sarigul NU, Sterlinski M, Linde C. CRT Survey II: a European Society of Cardiology survey of cardiac resynchronisation therapy in 11 088 patients‐who is doing what to whom and how? Eur J Heart Fail 2018; 20: 1039–1051. - PubMed
    1. Leclercq C, Walker S, Linde C, Clementy J, Marshall AJ, Ritter P, Djiane P, Mabo P, Levy T, Gadler F, Bailleul C, Daubert JC. Comparative effects of permanent biventricular and right‐univentricular pacing in heart failure patients with chronic atrial fibrillation. Eur Heart J 2002; 23: 1780–1787. - PubMed