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Impact of chronic atrial fibrillation in patients with severe heart failure and indication for CRT

Data of two registries with 711 patients (1999–2006 and 2007–6/2008)

Chronisches Vorhofflimmern bei schwerer Herzinsuffizienz und CRT-Indikation

Daten aus zwei Registern zu 711 Patienten (1999–2006 und 2007–6/2008)

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Herzschrittmachertherapie + Elektrophysiologie Aims and scope Submit manuscript

Abstract

Aims

Atrial fibrillation (AF) is a relevant comorbidity in heart failure (HF) patients. In milestone cardiac resynchronization therapy (CRT) studies, patients with AF were excluded. We sought to investigate the influence of chronic atrial fibrillation (AF) on patients with CRT. AV node (AVN) ablation is frequently recommended. Converting AF to sinus rhythm (SR) is not a standard concept.

Methods

A total of 584 consecutive patients with CRT devices were included in a single-center registry from 1999–2006 (retrospective registry) and 127/324 patients from 2007–06/2008 (prospective registry). The impact of persistent AF (group 1) on clinical and echocardiographic improvement compared with patients in SR (group 2) after 12 (6) months follow-up were analyzed. Re-establishing SR after initial cardioversion or need for AVN ablation was examined.

Results

In the retrospective registry, 139 (24%) patients presented with AF (group 1) and 445 with SR (group 2). The groups differed in age, gender, and left atrium (LA) size but not in NYHA class, ejection fraction (EF), left ventricular end-diastolic dimension (LVEDD), B-type natriuretic peptide (BNP) levels, QRS width, and underlying disease. After 1 year, CRT improvement of NYHA class and EF was similar with higher mortality in group 1 (12% vs. 7%; OR 1.80; 95% confidence interval 0.95–3.4). The AF group presented with SR in 33/82 (40%) patients and 11% needed AVN ablation. The prospective data showed 27 (21%) patients in AF with conversion to SR in 41% after 6 months.

Conclusion

Patients with severe HF and chronic AF had a comparable improvement with CRT as those in SR. CRT is a successful treatment option in patients with chronic AF offering the potential to restore SR in a significant number of patients.

Zusammenfassung

Ziele

Vorhofflimmern (VF) ist eine wesentliche Komorbidität bei Herzinsuffizienz. In wegweisenden Studien zur Resynchronisationstherapie („cardiac resynchronization therapy“, CRT) stellte Vorhofflimmern (VF) ein Ausschlusskriterium dar. Ziel unserer Studie war es, der Einfluss von chronischem VF auf CRT-Patienten zu untersuchen. Häufig wird eine AV-Knoten-Ablation empfohlen; die Kardioversion in einen Sinusrhythmus (SR) ist kein Standardkonzept.

Methoden

Insgesamt 584 konsekutive Patienten mit CRT-Geräten wurden in ein unizentrisches Register zwischen 1999 und 2006 (retrospektives Register) aufgenommen, ferner 127 von 324 Patienten zwischen 2007 und 06/2008 (prospektives Register). Der Einfluss von persistierendem VF (Patientengruppe 1) auf klinische und echokardiographische Besserung im Vergleich mit Patienten im SR (Gruppe 2) nach 12 (6) Monaten Follow-up-Zeit wurde analysiert. Bewertet wurde die Re-Etablierung eines SR nach initialer Kardioversion bzw. AV-Knoten-Ablation.

Ergebnisse

Von den Patienten des retrospektiven Registers wiesen 139 (24%) ein VF auf (Gruppe 1) und 445 einen SR (Gruppe 2). Unterschiede zwischen den Gruppen bestanden hinsichtlich Alter, Geschlecht und LA-Durchmesser, nicht aber hinsichtlich NYHA-Klasse, Ejektionsfraktion (EF), linksventrikulärem enddiastolischem Durchmesser, BNP(Typ-B-natriuretisches Peptid)-Konzentration, QRS-Breite und Grunderkrankung. Nach einem Jahr CRT hatten sich NYHA-Klasse und EF ähnlich verbessert, dabei war die Mortalität in Gruppe 1 höher (12 vs. 7%; OR 1,80; 95%-KI 0,95–3,4). In der AF-Gruppe hatten 33 von 82 (40%) Patienten einen SR, bei 11% war eine AV-Knoten-Ablation erforderlich. Die prospektiven Daten zeigten bei 27 (21%) Patienten ein VF mit Konversion zum SR nach sechs Monaten in 41%.

Schlussfolgerung

Von einer CRT profitierten Patienten mit schwerer Herzinsuffizienz und chronischem VF ähnlich wie Patienten im Sinusrhythmus. CRT ist eine erfolgreiche Option bei chronischer VF und bietet einer signifikanten Anzahl von Patienten das Potenzial für die Wiederherstellung des Sinusrhythmus.

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Acknowledgment

We thank Mirja Knappe for the data collection, Axel Korte for software support for the registry, and Hans-Jörg Dirks for statistical analyses.

Conflict of interest

The corresponding author states that there are no conflicts of interest.

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Authors and Affiliations

  1. Department of Cardiology, Schuechtermann-Klinik, Heart Center Osnabrueck-Bad Rothenfelde, Ulmenallee 11, 49214, Bad Rothenfelde, Germany

    G. Luedorff, R. Grove, M. Kowalski, E. Wolff, J. Thale & W. Kranig

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  1. G. Luedorff
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  2. R. Grove
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  3. M. Kowalski
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  4. E. Wolff
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  5. J. Thale
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Correspondence to G. Luedorff.

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Luedorff, G., Grove, R., Kowalski, M. et al. Impact of chronic atrial fibrillation in patients with severe heart failure and indication for CRT. Herzschr. Elektrophys. 22, 226–232 (2011). https://doi.org/10.1007/s00399-011-0155-9

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