title: Long-term survival in patients undergoing cardiac resynchronization therapy: the importance of performing atrio-ventricular junction ablation in patients with permanent atrial fibrillation.
abstract: OBJECTIVE
  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.
  
  
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Electrophysiology and Pacing Unit, IRCCS Istituto Clinico Humanitas Rozzano-Milano, Via Manzoni 56, Rozzano, Milano IT-2089, Italy. maurizio.gasparini@humanitas.it
authors.forename: Maurizio
authors.initials: M
authors.lastname: Gasparini
authors.forename: Angelo
authors.initials: A
authors.lastname: Auricchio
authors.forename: Marco
authors.initials: M
authors.lastname: Metra
authors.forename: François
authors.initials: F
authors.lastname: Regoli
authors.forename: Cecilia
authors.initials: C
authors.lastname: Fantoni
authors.forename: Barbara
authors.initials: B
authors.lastname: Lamp
authors.forename: Antonio
authors.initials: A
authors.lastname: Curnis
authors.forename: Juergen
authors.initials: J
authors.lastname: Vogt
authors.forename: Catherine
authors.initials: C
authors.lastname: Klersy
mesh_terms: D001281:Atrial Fibrillation / Q000150:complications / Q000401:mortality / Q000628:therapy*; D002304:Cardiac Pacing, Artificial / Q000401:mortality*; D017115:Catheter Ablation / Q000401:mortality*; D002908:Chronic Disease; D003131:Combined Modality Therapy / Q000401:mortality; D005260:Female; D006333:Heart Failure / Q000150:complications / Q000401:mortality*; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D010138:Pacemaker, Artificial; D019919:Prosthesis Implantation / Q000401:mortality; D016019:Survival Analysis