Hot Line - AV junction ablation combined with cardiac resynchronisation therapy reduces mortality in patients with permanent AF and narrow QRS
28 Aug 2021
Hot Line presented at ESC Congress
The first part of the two-phase APAF-CRT trial demonstrated that atrioventricular (AV) junction ablation combined with cardiac resynchronisation therapy (CRT) reduced heart failure (HF)-associated hospitalisation and improved HF symptoms compared with optimal pharmacological rate control after 2 years in patients with permanent atrial fibrillation (AF) and a narrow QRS.1
In a Hot Line session today, Professor Michele Brignole (Istituto Auxologico Italiano, IRCCS, Ospedale San Luca, Milan, Italy) presented results from the second phase of APAF-CRT. This was an international, randomised, open-label trial in patients with severely symptomatic permanent AF (>6 months), with QRS ≤110 ms and at least one HF-associated hospitalisation in the previous year. Patients were randomised 1:1 to ablation + CRT or pharmacological management. Defibrillator use in both arms was at the investigator’s discretion.
Conducted in a larger population with a longer follow-up than the first phase, the second phase of APAF-CRT had a primary endpoint of death from any cause and was stopped for efficacy at the interim analysis after a median of 29 months of follow-up.
Among 133 patients randomised, there was a 74% reduction in the risk of all-cause death with ablation + CRT (7 patients, 11%) compared with pharmacological management (20 patients, 29%) (hazard ratio [HR] 0.26; 95% confidence interval [CI] 0.10 to 0.65; p=0.004). The estimated mortality rates at 4 years were 14% with ablation + CRT and 41% with pharmacological management. The relative and absolute risk reductions at 4 years were 74% and 27%, respectively, and the number needed to treat was 3.7. Ablation + CRT also reduced the combined secondary endpoint of all-cause mortality and HF hospitalisation by 60% (95% CI 0.22 to 0.73; p=0.002).
Regarding the lower mortality rate with ablation + CRT compared with pharmacological management, Prof. Brignole said, “We hypothesise that the observed benefit was due to the combination of the strict rate control and rate regularisation achieved by AV junction ablation, together with biventricular pacing which counteracted the adverse effects of right ventricular pacing.” And he suggested that, “The improvement in survival shown by the APAF-CRT trial supports ablation plus CRT as a first-line therapy in patients with permanent AF, narrow QRS and previous hospitalisation for HF.”
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1. Brignole M, et al. Eur Heart J. 2018;39:3999–4008.