AV Nodal Ablation Ups Survival in AF Patients With CRT

February 23, 2012

February 22, 2012 (Adelaide, Australia) — Atrioventricular (AV) nodal ablation significantly improves survival in heart-failure patients with atrial fibrillation (AF) who receive cardiac resynchronization therapy (CRT), suggests a meta-analysis that included < 1000 patients from a handful of studies, none of them randomized trials [1].

The catheter-ablation strategy was associated with reduced all-cause and cardiovascular mortality in three retrospective cohort studies and improved NYHA functional class in three other cohort studies, report Dr Anand N Ganesan (University of Adelaide and Royal Adelaide Hospital, Australia) and associates in the February 21, 2012 issue of the Journal of the American College of Cardiology.

The meta-analysis included studies of patients eligible for and receiving CRT without regard to NYHA functional class; they encompassed 339 patients who underwent AV junction ablation and 429 other patients with AF treated medically.

Mortality outcomes were available from three of the six studies.

Risk ratio (95% CI) for clinical end points with vs without AV nodal ablation in patients with systolic heart failure and AF receiving CRT

End point RR (95% CI) p
All-cause mortality 0.42 (0.26–0.68) < 0.001
Cardiovascular mortality 0.44 (0.24–0.81) 0.008


In addition, NYHA functional class improved significantly more in patients with AV nodal ablation compared with those with medically managed AF in the four studies with NYHA data. On the other hand, there was no significant difference in change in LVEF between the ablation and no-ablation groups in the three studies with LVEF numbers at baseline and follow-up.

Mean differences in NYHA class and LVEF with vs without AV nodal ablation in patients with systolic heart failure and AF receiving CRT

End point Mean difference (95% CI) p
NYHA functional class (%) –0.34 (–0.56 to –0.13) 0.002
LVEF (%) 6.1 (–3.5 to 15.8) 0.2


"To confirm these data, prospective evaluation of AV nodal ablation in CRT [patients with AF] by randomized controlled trial is warranted," Ganesan et al write.

An accompanying editorial is less tentative on what the meta-analysis seems to accomplish [2]. It "provides an important contribution confirming unequivocal favorable results of AV junction ablation in AF patients treated with CRT," write Drs Maurizio Gasparini and Paola Galimberti (IRCCS Istituto Clinico Humanitas, Milano, Italy). Gasparini is a coauthor on at least two of the six studies included in the meta-analysis.

Calling the observed all-cause and CV mortality reductions "dramatic," Gasparini and Galimberti write that "a complete effect of CRT may be achieved in AF patients only via AV junction ablation."

"Ganesan is supported by a Cardiovascular Lipid Research Grant from Pfizer Australia," according to the report, which also provides disclosures for the other authors. Gasparini discloses serving on advisory boards for Medtronic and Boston Scientific; Galimberti had no relevant disclosures.