title: Role of AV nodal ablation in cardiac resynchronization in patients with coexistent atrial fibrillation and heart failure a systematic review.
abstract: OBJECTIVE
  The aim of this study was to systematically review the medical literature to evaluate the impact of AV nodal ablation in patients with heart failure and coexistent atrial fibrillation (AF) receiving cardiac resynchronization therapy (CRT).
  
  
  BACKGROUND
  CRT has a substantial evidence base in patients in sinus rhythm with significant systolic dysfunction, symptomatic heart failure, and prolonged QRS duration. The role of CRT is less well established in AF patients with coexistent heart failure. AV nodal ablation has recently been suggested to improve outcomes in this group.
  
  
  METHODS
  Electronic databases and reference lists through September 15, 2010, were searched. Two reviewers independently evaluated citation titles, abstracts, and articles. Studies reporting the outcomes after AV nodal ablation in patients with AF undergoing CRT for symptomatic heart failure and left ventricular dyssynchrony were selected. Data were extracted from 6 studies, including 768 CRT-AF patients, composed of 339 patients who underwent AV nodal ablation and 429 treated with medical therapy aimed at rate control alone.
  
  
  RESULTS
  AV nodal ablation in CRT-AF patients was associated with significant reductions in all-cause mortality (risk ratio: 0.42 [95% confidence interval: 0.26 to 0.68]), cardiovascular mortality (risk ratio: 0.44 [95% confidence interval: 0.24 to 0.81]), and improvement in mean New York Heart Association functional class (risk ratio: -0.52 [95% confidence interval: -0.87 to -0.17]).
  
  
  CONCLUSIONS
  AV nodal ablation was associated with a substantial reduction in all-cause mortality and cardiovascular mortality and with improvements in New York Heart Association functional class compared with medical therapy in CRT-AF patients. Randomized controlled trials are warranted to confirm the efficacy and safety of AV nodal ablation in this patient population.
authors.affiliation: Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Australia.
authors.forename: Anand N
authors.initials: AN
authors.lastname: Ganesan
authors.forename: Anthony G
authors.initials: AG
authors.lastname: Brooks
authors.forename: Kurt C
authors.initials: KC
authors.lastname: Roberts-Thomson
authors.forename: Dennis H
authors.initials: DH
authors.lastname: Lau
authors.forename: Jonathan M
authors.initials: JM
authors.lastname: Kalman
authors.forename: Prashanthan
authors.initials: P
authors.lastname: Sanders
mesh_terms: D001281:Atrial Fibrillation / Q000150:complications / Q000601:surgery*; D001283:Atrioventricular Node / Q000601:surgery*; D058406:Cardiac Resynchronization Therapy / Q000379:methods*; D017115:Catheter Ablation; D006333:Heart Failure / Q000150:complications / Q000628:therapy*; D006801:Humans; D016896:Treatment Outcome