Managing atrial fibrillation in the CRT patient: Controversy or consensus? Gaurav A. Upadhyay, MD, Jonathan S. Steinberg, MD Heart Rhythm Volume 9, Issue 8, Pages S51-S59 (August 2012) DOI: 10.1016/j.hrthm.2012.04.030 Copyright © 2012 Heart Rhythm Society Terms and Conditions
Figure 1 Probability of survival in biventricular pacing patients, with or without atrial fibrillation, as a function of percentage of biventricular pacing capture. Patients with biventricular pacing >99.6% experienced a 24% reduction in mortality compared with the other groups (hazard ratio 0.76, P <.001). (Adapted from Hayes DL, Boehmer JP, Day JD, et al. Cardiac resynchronization therapy and the relationship of percent biventricular pacing to symptoms and survival. Heart Rhythm 2011;8:1469–1475.28) Heart Rhythm 2012 9, S51-S59DOI: (10.1016/j.hrthm.2012.04.030) Copyright © 2012 Heart Rhythm Society Terms and Conditions
Figure 2 Increasingly severe atrial fibrillation (AF) is associated with increased probability of implantable cardioverter-defibrillator (ICD) shocks (left) and increased risk of congestive heart failure (HF) deterioration (right). (Adapted from Rienstra M, Smit MD, Nieuwland W, et al. Persistent atrial fibrillation is associated with appropriate shocks and heart failure in patients with left ventricular dysfunction treated with an implantable cardioverter defibrillator. Am Heart J 2007;153:120–126.31) Heart Rhythm 2012 9, S51-S59DOI: (10.1016/j.hrthm.2012.04.030) Copyright © 2012 Heart Rhythm Society Terms and Conditions
Figure 3 New-onset atrial fibrillation (AF) is associated with statistically significant increases in risk of both appropriate and inappropriate implantable cardioverter-defibrillator shocks (A, B) as well as hospitalization (C). There is no statistically significant difference in risk of mortality (D). SR = sinus rhythm. (Modified from Borleffs CJ, Ypenburg C, van Bommel RJ, et al. Clinical importance of new-onset atrial fibrillation after cardiac resynchronization therapy. Heart Rhythm 2009;6:305–310.19) Heart Rhythm 2012 9, S51-S59DOI: (10.1016/j.hrthm.2012.04.030) Copyright © 2012 Heart Rhythm Society Terms and Conditions
Figure 4 Results from the Atrial Fibrillation and Congestive Heart Failure (AF-CHF) trial found that 27% of patients in the rhythm-control arm still demonstrated atrial fibrillation at 4 years of follow-up. Heart Rhythm 2012 9, S51-S59DOI: (10.1016/j.hrthm.2012.04.030) Copyright © 2012 Heart Rhythm Society Terms and Conditions
Figure 5 Meta-analysis of 5 trials of pulmonary vein isolation (PVI) vs optimal medical therapy found a cumulative odds ratio ∼16 for freedom from paroxysmal atrial fibrillation at 12 months after PVI. (Modified from Piccini JP, Lopes RD, Kong MH, Hasselblad V, Jackson K, Al-Khatib SM. Pulmonary vein isolation for the maintenance of sinus rhythm in patients with atrial fibrillation: a meta-analysis of randomized, controlled trials. Circ Antiarrhythm Electrophysiol 2009;2:626–633.52) Heart Rhythm 2012 9, S51-S59DOI: (10.1016/j.hrthm.2012.04.030) Copyright © 2012 Heart Rhythm Society Terms and Conditions
Figure 6 Meta-analysis of 7 studies shows similar success with pulmonary vein isolation (PVI) in patients with left ventricular dysfunction and those with normal ejection fraction (RR 1.00; A). In addition, there was a significant improvement in left ventricular ejection fraction after PVI (B). (From an abstract presented at the 2011 American College of Cardiology Scientific Sessions by Garikipati NV, Avula A, Verma P, Mittal S, Steinberg J. Pulmonary vein isolation in patients with left ventricular dysfunction: a meta-analysis. J Am Coll Cardiol 2011;57:E16.55) Heart Rhythm 2012 9, S51-S59DOI: (10.1016/j.hrthm.2012.04.030) Copyright © 2012 Heart Rhythm Society Terms and Conditions