![]() ![]() After multivariable analysis, only the CRT mode remained an independent predictor of clinical benefit (p=0.001).Īs no clinical difference was observed in the outcome of patients treated with biventricular pacing who met the current guideline indications, with those who did not, the results from the APAF study suggest that the indications for CRT should be extended to all patients with severely symptomatic AF undergoing AV junction ablation. In patients affected by severely symptomatic permanent AF, patients had a greater benefit from AV junction ablation and CRT pacing than RV-paced patients irrespective of the severity of the underlying structural heart disease and of current guidelines criteria. Furthermore, beneficial effects from CRT were consistent in patients who met the current recommendations from expert consensus for CRT, ejection fraction ≤35%, NYHA class ≥III and QRS width ≥120, (class IIa, level of evidence B), as well as in those who did not. With biventricular pacing however, 83% improved, 5% had no change and 12 % had a worsened clinical condition (p=0.001 versus RV pacing). In a sub-analysis on 171 patients of the recent APAF trial (14), 63% of patients had improved clinical conditions, 9% had no change and 28 % worsened with RV pacing during a median follow-up of 20 months. Resynchronisation therapy (CRT) achieved through AV junction ablation can restore proper synchrony. Likewise, the LV septum is activated before the LV free wall causing intraventricular dyssynchrony. the right ventricle is activated before the left, thus causing inter-ventricular dyssynchrony. Indeed, right ventricular pacing induces a ventricular activation sequence resembling that of left bundle branch block, i.e. ![]() However, AV junction ablation and permanent right ventricular (RV) pacing cause a non-physiologic asynchronous contraction which might partly counteract any beneficial effects of ablation. In a recent sub-analysis of the APAF trial (14), when compared with the pre-ablation evaluation in quality of life scores, great improvement in exercise capacity and cardiac performance was observed at 6 months (Table 1). In fact, randomised observational studies from the last two decades having enrolled in total over a thousand patients have shown that, AV junction ablation and permanent pacing from the RV apex provide efficient rate control, regularisation of AF and improve symptoms without deterioration of the ventricular function (6-13). ![]() Study results reflect the portion of the physician body who might not refer for intervention because they consider that AV junction ablation merely a palliative or even a potentially harmful.Īccording to guidelines (5), the patients candidates to AV junction ablation are those who: 1) due to high and irregular ventricular rate, had severe symptoms of palpitations, fatigue and shortness of breath during physical activity and at rest with chest discomfort greatly impairing quality of life Or 2) having a CRT indication due to drug-refractory heart failure, depressed left ventricular (LV) function and wide QRS complexes, have the need to avoid competitive atrial rhythm in order to assure a constant biventricular pacing Although it was observed that atrioventricular (AV) junction ablation and pace-maker implantation had been indicated in 8.6% of patients according to class I indication of Italian guidelines (5) only 2.7% were recommended the intervention by the attending cardiologist. In a prospective, observational, transversal study on the management of AF as primary diagnosis in Italy, we enrolled consecutive in- and out-patients referred to 43 different cardiology departments (4). The initial challenge is to properly detect patients who could benefit from AV junction ablation and pacing. Incidence of atrial fibrillation per 1000 person-years is 3.1 and 1.9 in 64-year-old men and women respectively, 19.2 in the 65-74 age bracket, and 31.4 in the over 80 population, which in Europe, roughly equates to six million and three and a half in the US, and figures are expected to rise as the population continues to age (1,2,3). Sixty percent of these have a permanent form of it, and forty per cent of these patients display severe symptoms, patients with uncontrolled congestive heart failure included. ![]()
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