Atrioventricular junction ablation combined with either right ventricular pacing or cardiac resynchronization therapy for atrial fibrillation

The need for large-scale randomized trials

David John Bradley, Win Kuang Shen

Research output: Contribution to journalArticle

36 Citations (Scopus)

Abstract

Background: Nonrandomized studies suggest that atrioventricular (AV) junction ablation and pacemaker implantation may improve quality of life, ejection fraction, and exercise tolerance in patients with symptomatic drug-refractory atrial fibrillation. Objective: The purpose of this study was to determine whether recent randomized trials support the use of AV junction ablation in combination with conventional right ventricular pacemaker therapy or cardiac resynchronization therapy (CRT) in atrial fibrillation. Methods: Meta-analysis of randomized trials comparing AV junction ablation vs drugs or CRT vs right ventricular pacing for atrial fibrillation. Results: Six randomized trials with 323 patients compared AV junction ablation vs pharmacologic therapy. The majority of these trials did not individually report a statistically significant improvement in survival, stroke, hospitalization, functional class, atrial fibrillation-associated symptoms, left ventricular ejection fraction, exercise capacity, healthcare costs, or quality of life. Overall, all-cause mortality was 3.5% for AV junction ablation patients and 3.3% for controls (relative risk 1.18, 99% confidence interval 0.26-5.22). Three randomized trials with 347 patients compared CRT vs right ventricular pacing in atrial fibrillation. These trials did not individually report a statistically significant improvement in survival, stroke, hospitalization, exercise capacity, or healthcare costs. CRT was associated with a statistically significant improvement in ejection fraction in two of the three trials. Overall, CRT was associated with a trend toward reduced all-cause mortality relative to controls (relative risk 0.51, 99% confidence interval 0.22-1.16). All-cause mortality was 7.1% for CRT patients and 14% for controls. Conclusion: Limited randomized trial data have been published regarding AV junction ablation in combination with conventional pacemaker therapy or CRT for atrial fibrillation. Large-scale randomized trials are needed to assess the efficacy of these therapies.

Original languageEnglish (US)
Pages (from-to)224-232
Number of pages9
JournalHeart Rhythm
Volume4
Issue number2
DOIs
StatePublished - Feb 2007

Fingerprint

Cardiac Resynchronization Therapy
Atrial Fibrillation
Health Care Costs
Mortality
Hospitalization
Stroke
Quality of Life
Confidence Intervals
Exercise
Exercise Tolerance
Survival
Therapeutics
Pharmaceutical Preparations
Stroke Volume
Meta-Analysis

Keywords

  • Ablation
  • Atrial fibrillation
  • Atrioventricular node
  • Cardiac resynchronization therapy
  • Clinical outcome
  • Meta-analysis
  • Pacemaker
  • Randomized trials
  • Survival

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

@article{e1fd3e6350c2498cb5c60b8811ffb627,
title = "Atrioventricular junction ablation combined with either right ventricular pacing or cardiac resynchronization therapy for atrial fibrillation: The need for large-scale randomized trials",
abstract = "Background: Nonrandomized studies suggest that atrioventricular (AV) junction ablation and pacemaker implantation may improve quality of life, ejection fraction, and exercise tolerance in patients with symptomatic drug-refractory atrial fibrillation. Objective: The purpose of this study was to determine whether recent randomized trials support the use of AV junction ablation in combination with conventional right ventricular pacemaker therapy or cardiac resynchronization therapy (CRT) in atrial fibrillation. Methods: Meta-analysis of randomized trials comparing AV junction ablation vs drugs or CRT vs right ventricular pacing for atrial fibrillation. Results: Six randomized trials with 323 patients compared AV junction ablation vs pharmacologic therapy. The majority of these trials did not individually report a statistically significant improvement in survival, stroke, hospitalization, functional class, atrial fibrillation-associated symptoms, left ventricular ejection fraction, exercise capacity, healthcare costs, or quality of life. Overall, all-cause mortality was 3.5{\%} for AV junction ablation patients and 3.3{\%} for controls (relative risk 1.18, 99{\%} confidence interval 0.26-5.22). Three randomized trials with 347 patients compared CRT vs right ventricular pacing in atrial fibrillation. These trials did not individually report a statistically significant improvement in survival, stroke, hospitalization, exercise capacity, or healthcare costs. CRT was associated with a statistically significant improvement in ejection fraction in two of the three trials. Overall, CRT was associated with a trend toward reduced all-cause mortality relative to controls (relative risk 0.51, 99{\%} confidence interval 0.22-1.16). All-cause mortality was 7.1{\%} for CRT patients and 14{\%} for controls. Conclusion: Limited randomized trial data have been published regarding AV junction ablation in combination with conventional pacemaker therapy or CRT for atrial fibrillation. Large-scale randomized trials are needed to assess the efficacy of these therapies.",
keywords = "Ablation, Atrial fibrillation, Atrioventricular node, Cardiac resynchronization therapy, Clinical outcome, Meta-analysis, Pacemaker, Randomized trials, Survival",
author = "Bradley, {David John} and Shen, {Win Kuang}",
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KW - Survival

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