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. 2021 Dec 17;2(6Part B):784-795.
doi: 10.1016/j.hroo.2021.09.003. eCollection 2021 Dec.

Atrial fibrillation in cardiac resynchronization therapy

Mark K Elliott  1   2 , Vishal S Mehta  1   2 , Dejana Martic  2 , Baldeep S Sidhu  1   2 , Steven Niederer  1 , Christopher A Rinaldi  1   2
Affiliations

Atrial fibrillation in cardiac resynchronization therapy

Mark K Elliott et al. Heart Rhythm O2. .

Abstract

Patients with atrial fibrillation (AF) were largely excluded from the major clinical trials of cardiac resynchronization therapy (CRT), despite the presence of AF in up to 40% of patients receiving CRT in clinical practice. AF appears to attenuate the response to CRT, by the combination of a reduction in biventricular pacing and the loss of atrioventricular synchrony. In addition, remodeling secondary to CRT may influence the progression of AF. Management options for patients with AF and CRT include rate control, with drugs or atrioventricular node ablation, or rhythm control, with electrical cardioversion and antiarrhythmic therapy, or AF catheter ablation. The evidence for these therapies in patients with CRT is largely limited to observational studies or inferred from randomized studies in the general heart failure population. In this review, we explore the complex interaction between AF, heart failure, and CRT and discuss the evidence for the treatment options in this difficult patient cohort.

Keywords: AF ablation; AV node ablation; Atrial fibrillation; Cardiac resynchronization therapy; Pulmonary vein isolation; Rate control; Rhythm control.

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Figures

Figure 1
Figure 1
Atrial fibrillation (AF) / atrial tachycardia (AT) is the most common etiology for loss of effective cardiac resynchronization therapy (CRT) pacing. As the percentage of CRT pacing decreases, the contribution of AT/AF to the loss increases. PVC = premature ventricular contraction; VSE = ventricular sensing episodes. Reproduced with permission from Cheng et al (2012).
Figure 2
Figure 2
Survival decreases with reducing biventricular (BiV) pacing in an observational analysis of 36,935 patients with cardiac resynchronization therapy defibrillators. A: Survival analysis by biventricular pacing percentage. B: Survival analysis by biventricular pacing percentage and by the presence of significant atrial fibrillation (AFib), defined as average daily burden >0.5%. Reproduced with permission from Hayes et al 2011.
Figure 3
Figure 3
Nonresponders have a low percentage of effective cardiac resynchronization therapy paced beats on Holter monitoring despite high (>90%) biventricular pacing percentage on device interrogation. Reproduced with permission from Kamath et al 2009.
Figure 4
Figure 4
Atrioventricular node ablation improves mortality in patients with atrial fibrillation and cardiac resynchronization therapy in a prospective observational study (CERTIFY trial). AFabl = patients with atrial fibrillation treated with atrioventricular node ablation; AFdrug = patients with atrial fibrillation treated with drugs alone; SR = patients in sinus rhythm. Reproduced with permission from Gasparini et al 2013.
Figure 5
Figure 5
Clinical flowchart of the management of patients with atrial fibrillation (AF) and cardiac resynchronization therapy (CRT). AAD = antiarrhythmic drugs; AV = atrioventricular; GDMT = guideline-directed medical therapy; HF = heart failure; LA = left atrial; LVEF = left ventricular ejection fraction.
See this image and copyright information in PMC

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