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CLINICAL RESEARCH: CARDIAC RESYNCHRONIZATION THERAPY

Cardiac Resynchronization in Patients With Atrial Fibrillation

A Meta-Analysis of Prospective Cohort Studies

Gaurav A. Upadhyay, MD^_*, Niteesh K. Choudhry, MD, PhD, Angelo Auricchio, MD, PhD, Jeremy Ruskin, MD^_* and Jagmeet P. Singh, MD, PhD^_*,_*

^_* Department of Medicine and the Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts
Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
Division of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland

Manuscript received March 3, 2008; revised manuscript received May 22, 2008, accepted June 7, 2008.

^_* Reprint requests and correspondence: Dr. Jagmeet P. Singh, Cardiac Arrhythmia Service, Cardiology Division, Gray Building 109, 55 Fruit Street, Boston, Massachusetts 02114 (Email: jsingh{at}partners.org).

Objectives: This study is a meta-analysis of prospective cohort studies comparing the impact of cardiac resynchronization therapy (CRT) for patients in atrial fibrillation (AF) and sinus rhythm (SR).

Background: Although close to one-third of advanced heart failure patients exhibit AF, the impact of CRT in this group remains unclear.

Methods: Prospective cohort studies comparing patients in normal SR and chronic AF treated with CRT were included. All studies reported death, New York Heart Association functional class, ejection fraction, 6-min walk test, and the Minnesota score or its equivalent as outcomes. Data sources included Ovid MEDLINE In-Process & Other Non-Indexed Citations, the Cochrane Central Register of Controlled Trials, the Database of Abstracts of Reviews of Effects, and the American College of Physicians Journal Club.

Results: Of 2,487 reports identified, 5 studies following a total of 1,164 patients were included. Both AF and SR patients benefited significantly from CRT. Mortality was not significantly different at 1 year (relative risk ratio: 1.57, 95% confidence interval [CI]: 0.87 to 2.81). The New York Heart Association functional class improved similarly for both groups (–0.90 for SR patients, –0.84 for AF patients). SR patients showed greater relative improvement in the 6-min walk test (11.6 m greater, 95% CI: 10.4 to 12.8 m) and the Minnesota score (3.9 points less, 95% CI: 3.4 to 4.5 points) than AF patients. AF patients, however, achieved a small but statistically significant greater change in ejection fraction (0.39% greater change in ejection fraction, 95% CI: 0.22% to 0.55%).

Conclusions: Patients in AF show significant improvement after CRT, with similar or improved ejection fraction as SR patients, but smaller benefits in regard to functional outcomes.

Key Words: atrial fibrillation • biventricular pacemaker • cardiac resynchronization • congestive heart failure treatment

Abbreviations and Acronyms   6MWD = 6-min walking distance   AF = atrial fibrillation   AVJ = atrioventricular junction   CI = confidence interval   CRT = cardiac resynchronization therapy   LVEF = left ventricular ejection fraction   MLWHF = Minnesota Living With Heart Failure   NYHA = New York Heart Association   QOL = quality of life

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