title: Mortality After Atrioventricular Nodal Radiofrequency Catheter Ablation With Permanent Ventricular Pacing in Atrial Fibrillation: Outcomes From a Controlled Nonrandomized Study Cardiac Resynchronization Therapy in Patients With Permanent Atrial Fibrillation: Results From the Resynchronization for Ambulatory Heart Failure Trial (RAFT) Outcomes of cardiac resynchronization therapy in patients with intermittent atrial fibrillation or atrial flutter in the COMPANION trial. Long-term benefits of biventricular pacing in congestive heart failure: results from the MUltisite STimulation in cardiomyopathy (MUSTIC) study. Frequency and Outcomes of Postrandomization Atrial Tachyarrhythmias in the Resynchronization/Defibrillation in Ambulatory Heart Failure Trial Effect of Cardiac Resynchronization on the Incidence of Atrial Fibrillation in Patients With Severe Heart Failure Long-term effects of cardiac resynchronisation therapy in patients with atrial fibrillation Impact of atrial fibrillation on early complications and one year-survival after cardioverter defibrillator implantation: results from the German DEVICE registry. Atrioventricular nodal ablation predicts survival benefit in patients with atrial fibrillation receiving cardiac resynchronization therapy. Pulmonary-vein isolation for atrial fibrillation in patients with heart failure. Comparison of usefulness of cardiac resynchronization therapy in patients with atrial fibrillation and heart failure versus patients with sinus rhythm and heart failure. A strategy to achieve CRT response in permanent atrial fibrillation without obligatory atrioventricular node ablation. Cardiac resynchronization therapy in patients with atrial fibrillation: a 2-year follow-up study. Sudden death after radiofrequency ablation of the atrioventricular node in patients with atrial fibrillation. Cardiac-resynchronization therapy for mild-to-moderate heart failure. The hemodynamic effect of intrinsic conduction during left ventricular pacing as compared to biventricular pacing. Digoxin Is Associated With Increased Shock Events and Electrical Storms in Patients With Implantable Cardioverter Defibrillators
abstract: Background —Atrioventricular nodal radiofrequency ablation ( AVNA ) with permanent ventricular pacing can be used to control rate in patients with atrial fibrillation ( AF ) . However , long-term outcomes after AVNA are uncertain , especially in light of irreversible pacemaker dependence . Methods and Results —We examined 9122 consecutive patients with AF . The outcomes in 453 patients with AVNA ( 26 % of whom underwent an implantable cardiac defibrillator implant and 37 % underwent cardiac resynchronization therapy implant ) were compared with AF patients without AVNA after propensity score 1:1 matching . During follow-up in the propensity-matched cohort ( 2.41±3.23 years , median 1.23 , quartiles 0.33–3.12 ) , 100 patients died ( yearly rate of death 6.6 % ) . Mode of death was available in 86 % of patients , which was cardiovascular in 67 % of the patients ( related to heart failure in 38 % , sudden death in 5 % , and other cardiovascular reason in 24 % ) and noncardiovascular in 33 % . AVNA in patients with AF was associated with a lower risk of mortality ( odds ratio 0.47 , 95 % confidence interval , 0.29–0.77 ; P=0.003 ) , a lower risk of cardiovascular mortality ( odds ratio = 0.41 , 95 % confidence interval 0.23–0.73 ; P=0.003 ) , and nonsignificant lower risk of stroke and thromboembolic events ( odds ratio = 0.61 , 95 % confidence interval 0.36–1.06 ; P=0.08 ) . Conclusions —In sick AF patients with multiple comorbidities  , AVNA with permanent ventricular pacing for rate control seems safe during follow-up and may be associated with lower mortality Background —Cardiac resynchronization ( CRT ) prolongs survival in patients with systolic heart failure and QRS prolongation . However , most trials excluded patients with permanent atrial fibrillation . Methods and Results —The Resynchronization for Ambulatory Heart Failure Trial ( RAFT ) r and omized patients to an implantable cardioverter defibrillator ( ICD ) or ICD+CRT , stratified by the presence of permanent atrial fibrillation . Patients with permanent atrial fibrillation were r and omized to CRT-ICD ( n=114 ) or ICD ( n=115 ) . Patients receiving a CRT-ICD were similar to those receiving an ICD  : age ( 71.6±7.3 versus 70.4±7.7 years ) , left ventricular ejection fraction ( 22.9±5.3 % versus 22.3±5.1 % ) , and QRS duration ( 151.0±23.6 versus 153.4±24.7 ms ) . There was no difference in the primary outcome of death or heart failure hospitalization between those assigned to CRT-ICD versus ICD ( hazard ratio , 0.96 ; 95 % CI , 0.65–1.41 ; P=0.82 ) . Cardiovascular death was similar between treatment arms ( hazard ratio , 0.97 ; 95 % CI , 0.55–1.71 ; P=0.91 ) ; however , there was a trend for fewer heart failure hospitalizations with CRT-ICD ( hazard ratio , 0.58 ; 95 % CI , 0.38–1.01 ; P=0.052 ) . The change in 6-minute hall walk duration between baseline and 12 months was not different between treatment arms ( CRT-ICD : 19±84 m versus ICD : 16±76 m ; P=0.88 ) . Patients treated with CRT-ICD showed a trend for a greater improvement in Minnesota Living with Heart Failure score between baseline and 6 months ( CRT-ICD : 41±21 to 31±21 ; ICD : 33±20 to 28±20 ; P=0.057 ) . Conclusions — Patients with permanent atrial fibrillation who are otherwise CRT c and i date s appear to gain minimal benefit from CRT-ICD compared with a st and ard ICD . Clinical Trial Registration —URL : http://www . clinical trials.gov . Unique identifier : NCT00251251 BACKGROUND Controlled clinical trial data are lacking for cardiac resynchronization therapy ( CRT ) outcomes in patients with advanced heart failure ( HF ) from reduced left ventricular ejection fraction ( HFrEF ) and intermittent atrial fibrillation or flutter ( IAF/AFL ) . OBJECTIVE The purpose of this study was to describe CRT outcomes in patients with IAF/AFL and advanced HF . METHODS HF outcomes in patients in the COMPANION ( Comparison of Medical Therapy , Pacing , and Defibrillation in Heart Failure ) trial with New York Heart Association class III or IV HFrEF , left ventricular ejection fraction ≤0.35 , sinus rhythm at r and omization , and no history of baseline arrhythmia were compared with those with a history of IAF/AFL . RESULTS In those with no history of baseline arrhythmia ( n = 887 ) , compared with optimal pharmacological therapy ( OPT ) with no CRT , the CRT + OPT arms exhibited a significant reduction in the end points of death or any hospitalization ( hazard ratio [ HR ] 0.73 [ 95 % Confidence Interval ( CI ) : 0.60 to 0.89 ] ; P = .002 ) and death or HF hospitalization ( HR 0.53 [ 95 % CI : 0.41 to 0.68 ] ; P < .001 ) . In contrast , in the IAF/AFL subgroup ( n = 293 ) , CRT did not result in improved outcomes compared with OPT ( death or any hospitalization : HR 1.16 [ 95 % CI : 0.83 to 1.63 ] ; P = .38 ; death or HF hospitalization : HR 0.97 [ 95 % CI : 0.64 to 1.46 ] ; P = .88 ) . The interaction between history of AF/AFL and CRT was statistically significant for both outcomes ( P < .05 ) . CONCLUSION In the COMPANION trial , patients with moderate to severe HFrEF and a history of IAF/AFL had no benefit from CRT OBJECTIVES The main objective of this study was to assess if the benefits of biventricular ( BiV ) pacing observed during the crossover phase were sustained over 12 months . BACKGROUND MUltisite STimulation In Cardiomyopathies ( MUSTIC ) is a r and omized controlled study intended to evaluate the effects of BiV pacing in patients with New York Heart Association ( NYHA ) class III heart failure and intraventricular conduction delay . METHODS Of 131 patients included , 42/67 in sinus rhythm ( SR ) and 33/64 in atrial fibrillation ( AF ) were followed up longitudinally at 9 and 12 months by 6-min walked distance , peak oxygen uptake ( peak VO(2 ) ) , quality of life by the Minnesota score , NYHA class , echocardiography , and left ventricular ejection fraction by radionuclide technique . RESULTS At 12 months , all SR and 88 % of AF patients were programmed to BiV pacing . Compared with baseline , the 6-min walked distance increased by 20 % ( SR ) ( p = 0.0001 ) and 17 % ( AF ) ( p = 0.004 ) ; the peak VO(2 ) by 11 % ( SR ) and 9 % ( AF ) ; quality of life improved by 36 % ( SR ) ( p = 0.0001 ) and 32 % ( AF ) ( p = 0.002 ) ; NYHA class improved by 25 % ( SR ) ( p = 0.0001 ) and 27 % ( AF ) ( p = 0.0001 ) . The ejection fraction improved by 5 % ( SR ) and 4 % ( AF ) . Mitral regurgitation decreased by 45 % ( SR ) and 50 % ( AF ) . CONCLUSIONS The clinical benefits of BiV pacing appeared to be significantly maintained over a 12-month follow-up period Background —Whether adding cardiac resynchronization therapy ( CRT-D ) to an implanted cardioverter – defibrillator alters the risk of atrial fibrillation or other atrial tachyarrhythmias ( AF/AT ) , or if postimplantation AF/AT modulate the benefits of CRT-D , remain unknown . Methods and Results —We studied 972 Resynchronization/Defibrillation in Ambulatory Heart Failure Trial ( RAFT ) participants without permanent AF , who were r and omized to CRT-D ( n=495 ) versus nonresynchronization defibrillator ( implanted cardioverter – defibrillator ; n=477 ) within the predefined stratum eligible for an atrial lead . Occurrence of postr and omization AF/AT was prospect ively assessed , and Cox models were used to test the independent association between the postr and omization AF/AT and the RAFT primary composite outcome of all-cause mortality or hospitalization for heart failure . Over 41 ( ±19 ) months , postr and omization AF/AT occurred in 216 ( 45.3 % ) patients r and omized to implanted cardioverter – defibrillator and 249 ( 50.3 % ) r and omized to CRT-D. After adjusting for competing risk of death , r and omization to CRT-D increased risk of postr and omization AF/AT ( hazard ratio , 1.20 ; 95 % confidence interval , 1.00–1.42 ; P=0.045 ) . Postr and omization AF/AT , which remained paroxysmal in 69.5 % , did not reduce biventricular pacing percentage . In adjusted models , postr and omization AF/AT was not associated with the primary outcome ( hazard ratio , 1.04 ; 95 % confidence interval , 0.84–1.30 ) . However , AF/AT was associated with a borderline decreased risk of mortality ( hazard ratio , 0.75 ; 95 % confidence interval , 0.58–1.00 ) but increased risk of heart failure hospitalization ( hazard ratio , 1.43 ; 95 % confidence interval , 1.08–1.90 ) . Conclusions —In RAFT , nearly half of the patients developed postr and omization AF/AT , and those r and omized to CRT-D had borderline significant higher risk . Postr and omization AF/AT was associated with risk of heart failure hospitalization , but not with the primary composite outcome . Clinical Trial Registration —URL : http://www . clinical trials.gov . Unique identifier : NCT00251251 Background — Atrial fibrillation/flutter ( AF ) and heart failure often coexist ; however , the effect of cardiac resynchronization therapy ( CRT ) on the incidence of AF and on the outcome of patients with new-onset AF remains undefined . Methods and Results — In the CArdiac REsynchronisation in Heart Failure ( CARE-HF ) trial , 813 patients with moderate or severe heart failure were r and omly assigned to pharmacological therapy alone or with the addition of CRT . The incidence of AF was assessed by adverse event reporting and by ECGs during follow-up , and the impact of new-onset AF on the outcome and efficacy of CRT was evaluated . By the end of the study ( mean duration of follow-up 29.4 months ) , AF had been documented in 66 patients in the CRT group compared with 58 who received medical therapy only ( 16.1 % versus 14.4 % ; hazard ratio 1.05 ; 95 % confidence interval , 0.73 to 1.50 ; P=0.79 ) . There was no difference in the time until first onset of AF between groups . Mortality was higher in patients who developed AF , but AF was not a predictor in the multivariable model ( hazard ratio 1.17 ; 95 % confidence interval , 0.82 to 1.67 ; P=0.37 ) . In patients with new-onset AF , CRT significantly reduced the risk for all-cause mortality and all other predefined end points and improved ejection fraction and symptoms ( no interaction between AF and CRT ; all P>0.2 ) . Conclusions — Although CRT did not reduce the incidence of AF , CRT improved the outcome regardless of whether AF developed Objective : To compare the effects of cardiac resynchronisation therapy ( CRT ) in patients with heart failure ( HF ) in either atrial fibrillation ( AF ) or sinus rhythm ( SR ) . Design : Prospect i ve observational study . Patients : 295 consecutive patients with HF ( permanent AF in 66 , paroxysmal AF in 20 , SR in 209 ; New York Heart Association ( NYHA ) class III or IV ; left ventricular ejection fraction ( LVEF ) ⩽35 % , QRS ⩾120 ms ) . Interventions : All patients underwent CRT without atrioventricular junction ablation . Main outcome measures : The primary end point was the composite of cardiovascular death or unplanned hospitalisation for major cardiovascular events . Secondary end points included the composite of cardiovascular death or hospitalisation for worsening HF . Cardiovascular mortality , total mortality and changes in NYHA class , 6-minute walking distance , quality of life ( Minnesota Living with Heart Failure question naire ) and echocardiographic variables were also considered . Results : Over a follow-up period of up to 6.8 years , no differences emerged between patients in AF or SR in any of the mortality or morbidity end points . The AF and SR groups derived similar improvements in mean NYHA class ( −1.3 vs –1.2 ) , 6-minute walking distance ( 92.3 vs 78.4 m ) and quality of life scores ( −25.2 vs –18.7 ) ( all p<0.001 ) . In both the AF and the SR groups , reductions were seen in left ventricular end-systolic ( −25.9 vs –34.5 ml , both p<0.001 ) and end-diastolic ( −20.2 ml , p = 0.001 vs 26.2 ml , p<0.001 ) volumes and improvements in LVEF ( 4.69 % vs 7.86 % , both p<0.001 ) . Conclusions : Cardiac resynchronisation therapy leads to similar prognostic and symptomatic benefits in patients in AF and SR , even without atrioventricular junction ablation . Echocardiographic improvements are also comparable AIMS AND OBJECTIVE Outcome data of patients with implantable cardioverter defibrillators ( ICD ) and atrial fibrillation ( AF ) are conflicting . The German DEVICE registry aims to add further information on this particular cohort . METHODS AND RESULTS The German DEVICE registry is a nationwide prospect i ve multicenter data base of ICD implantations . 3261 patients are included ( 81 % males , 2701 ( 82.8 % ) first ICD implantations , 560 ( 17.2 % ) ICD replacements ) .  Cardiac resynchronization therapy ( CRT-D ) was performed in 882 patients ( 27.0 % ) . Sinus rhythm ( SR ) was present in 2654 ( 81.4 % ) and atrial fibrillation ( AF ) in 607 ( 18.6 % ) . Left ventricular ejection fraction ( LVEF ) did not differ between groups ( SR 32.3 % , AF 30.4 % ; p = 0.09 ) . AF patients were older ( AF 70.9 versus SR 63.9 years ; p < 0.0001 ) , presented with more co-morbidities ( diabetes , hypertension , chronic kidney disease ; all p < 0.001 ) . In-hospital complications were not significantly different between groups ( p = 0.58 ) . Follow-up information after one year was available in 2967 patients ( 91 % ) . One-year overall mortality after first ICD implantation was 4.9 % for SR and 11.2 % for AF patients ( p < 0.0001 ) ; mortality one year after ICD replacement was 8.4 % for SR and 12.0 % for AF ( p = 0.34 ) . No statistically significant difference between SR and AF patients receiving a CRT device was observed ( SR 6.9 % , AF 10.7 % , p = 0.16 ) in terms of one-year mortality . CONCLUSION The German DEVICE registry demonstrates that patients with AF who receive ICD devices are older , have more co-morbidity and more severe heart failure . AF carries an independent 1.39 fold risk ( 95 % CI 1.02 - 1.89 ) of death after one year in patients only with first ICD implantation BACKGROUND Cardiac resynchronization therapy ( CRT ) benefits patients with advanced heart failure . The role of atrioventricular nodal ( AVN ) ablation in improving CRT outcomes , including survival benefit in CRT recipients with atrial fibrillation , is uncertain . OBJECTIVE The purpose of this study was to assess the impact of AVN ablation on clinical and survival outcomes in a large atrial fibrillation and heart failure population that met the current indication for CRT and to determine whether AVN ablation is an independent predictor of survival in CRT recipients . METHODS Of 154 patients with atrial fibrillation who received CRT-D , 45 ( 29 % ) underwent AVN ablation ( + AVN-ABL group ) , whereas 109 ( 71 % ) received drug therapy for rate control during CRT ( -AVN-ABL group ) . New York Heart Association ( NYHA ) class , electrocardiogram , and echocardiogram were assessed before and after CRT .  Survival data were obtained from the national death and location data base ( Accurint ) . RESULTS CRT comparably improved left ventricular ejection fraction ( 8.1 % + /- 10.7 % vs 6.8 % + /- 9.6 % , P = .49 ) and left ventricular end-diastolic diameter ( -2.1 + /- 5.9 mm vs -2.1 + /- 6.7 mm , P = .74 ) in both + AVN-ABL and -AVN-ABL groups . Improvement in NYHA class was significantly greater in the + AVN-ABL group than in -AVN-ABL group ( -0.7 + /- 0.8 vs -0.4 + /- 0.8 , P = .04 ) . Survival estimates at 2 years were 96.0 % ( 95 % confidence interval [ CI ] 88.6%-100 % ) for + AVN-ABL group and 76.5 % ( 95 % CI 68.1%-85.8 % ) for-AVN-ABL group ( P = .008 ) . AVN ablation was independently associated with survival benefit from death ( hazard ratio [ HR ] 0.13 , 95 % CI 0.03 - 0.58 , P = .007 ) and from combined death , heart transplant , and left ventricular assist device ( HR 0.19 , 95 % CI 0.06 - 0.62 , P = .006 ) after CRT . CONCLUSION Among patients with atrial fibrillation and heart failure receiving CRT , AVN ablation for definitive biventricular pacing provides greater improvement in NYHA class and survival benefit . Larger-scale r and omized trials are needed to assess the clinical and survival outcomes of this therapy BACKGROUND Pulmonary-vein isolation is increasingly being used to treat atrial fibrillation in patients with heart failure . METHODS In this prospect i ve , multicenter clinical trial , we r and omly assigned patients with symptomatic , drug-resistant atrial fibrillation , an ejection fraction of 40 % or less , and New York Heart Association class II or III heart failure to undergo either pulmonary-vein isolation or atrioventricular-node ablation with biventricular pacing .  All patients completed the Minnesota Living with Heart Failure question naire ( scores range from 0 to 105 , with a higher score indicating a worse quality of life ) and underwent echocardiography and a 6-minute walk test ( the composite primary end point ) . Over a 6-month period , patients were monitored for both symptomatic and asymptomatic episodes of atrial fibrillation . RESULTS In all , 41 patients underwent pulmonary-vein isolation  , and 40 underwent atrioventricular-node ablation with biventricular pacing ; none were lost to follow-up at 6 months . The composite primary end point favored the group that underwent pulmonary-vein isolation , with an improved question naire score at 6 months ( 60 , vs. 82 in the group that underwent atrioventricular-node ablation with biventricular pacing ; P<0.001 ) , a longer 6-minute-walk distance ( 340 m vs. 297 m , P<0.001 ) , and a higher ejection fraction ( 35 % vs. 28 % , P<0.001 ) . In the group that underwent pulmonary-vein isolation , 88 % of patients receiving antiarrhythmic drugs and 71 % of those not receiving such drugs were free of atrial fibrillation at 6 months . In the group that underwent pulmonary-vein isolation , pulmonary-vein stenosis developed in two patients , pericardial effusion in one , and pulmonary edema in another ; in the group that underwent atrioventricular-node ablation with biventricular pacing , lead dislodgment was found in one patient and pneumothorax in another . CONCLUSIONS Pulmonary-vein isolation was superior to atrioventricular-node ablation with biventricular pacing in patients with heart failure who had drug-refractory atrial fibrillation . ( Clinical Trials.gov number , NCT00599976 . The prevalence of atrial fibrillation ( AF ) in patients with heart failure is high , but data about the effects of cardiac resynchronization therapy ( CRT ) in patients with chronic AF are scarce . In this prospect i ve observational study of 263 consecutive patients , CRT was performed in 96 patients ( 37 % ) with chronic AF and 167 patients ( 63 % ) with sinus rhythm ( SR ) .  Echocardiographic and clinical parameters were evaluated at baseline and 3 and 12 months . Reverse left ventricular ( LV ) remodeling is defined as LV end-systolic volume decrease > or = 10 % . Hospitalization rates for heart failure in the year before and after implantation were compared . Baseline characteristics between patients with and without AF were similar , but the AF group had smaller LV end-systolic and end-diastolic volumes and larger left atrial dimensions . New York Heart Association class , 6-minute walking distance , quality -of-life score , LV ejection fraction , and mitral regurgitation improved significantly at 3 and 12 months in both groups , and the changes were similar . Reverse LV remodeling after 3 and 12 months was 74 % and 82 % ( AF group ) versus 77 % and 83 % , respectively ( SR group , p = 0.79 ) . After 1 year , cardioversion had occurred in 25 % of patients with AF . In the year after implantation , significant decreases in hospitalizations for heart failure in both groups ( 84 % and 90 % ) were documented . Long-term mortality was almost equal in both groups . In conclusion , this large-scale study shows that the benefit of CRT in patients with chronic AF and heart failure is similar to that in patients with SR . Patients with chronic AF and heart failure should be considered c and i date s for CRT BACKGROUND Cardiac resynchronization therapy ( CRT ) is an established method in patients with severe heart failure and wide QRS configuration , particularly during sinus rhythm ( SR ) . In CRT patients with permanent atrial fibrillation ( AF ) , there is no general consensus regarding the need for atrioventricular node ( AVN ) ablation . The aim of this study was to evaluate the benefit of CRT in permanent AF with and without AVN ablation . METHODS New York Heart Association classification , QRS duration , and echocardiographic parameters were assessed before and after CRT with a follow-up of 12 ± 3 months . Two hundred thirty patients in SR and 46 patients with permanent AF of 2.1 ± 0.5 years duration were studied .  AVN ablation was performed only in AF patients with insufficient pharmacological rate control evidence d by ≤80 % ventricular stimulation . RESULTS Fifteen AF patients underwent AVN ablation . Biventricular pacing comparably improved functional status , left ventricular ejection fraction , and left ventricular end-diastolic dimensions in all treated groups . Biventricular stimulation percentage was 10 % lower in pharmacologically treated AF patients over 1 year as compared to patients in SR and to AF patients undergoing AVN ablation , which did not affect outcome in this patient population . CONCLUSION In patients with permanent AF and CRT , an AVN ablation strategy might not be strictly required in all patients INTRODUCTION Atrial fibrillation ( AF ) is the most common arrhythmia in patients with heart failure ( HF ) and represents an important comorbidity in these patients . Cardiac resynchronization therapy ( CRT ) has been shown to be beneficial in patients with HF . Whether patients with AF benefit similarly from CRT as their counterparts in sinus rhythm is controversial . METHODS AND RESULTS We conducted a cohort analysis of 175 patients ( 138 men ; age range 57 - 79 years ) who underwent CRT implantation during 2004 - 2008 in our institution . AF was documented in 66 patients ( 37.7 % of patients , 52 men ) . There were no differences in 1- or 2-year mortality between patients with and without AF ( 13.6 % vs 11.79 % , P = 0.7 ; 25.8 % vs 16.9 % , P = 0.2 , respectively ) . There were no differences between the groups in the rate of complications after CRT implantation or in the rate of appropriate electrical shocks . In the subgroup of AF patients with cardiac resynchronization therapy defibrillator ( CRT-D ) ( n = 32 , 48.5 % ) , the 1-year mortality was 3.1 % as compared to 23.5 % in AF patients with cardiac resynchronization therapy pacemaker ( P = 0.03 ) . This difference was no longer evident after 2 years ( 25.0 % vs 26.5 % , P = 0.8 , respectively ) . Ten patients ( 15.2 % ) with AF underwent atrioventricular ( AV ) node ablation . The 2-year mortality of these patients was 10.0 % as compared to 28.6 % in AF patients who did not undergo AV-node ablation ( P = 0.4 ) . CONCLUSIONS In this study , no difference in mortality appears to exist between patients with or without AF and who undergo CRT implantation . Our findings of the beneficial effects of AV-node ablation and CRT-D in AF patients deserve further investigation OBJECTIVES We evaluated the incidence and predictors of sudden death after  atrioventricular ( AV ) node ablation and pacemaker implantation .  BACKGROUND Sudden death may occur after radiofrequency catheter ablation of the AV node and pacemaker implantation in patients with atrial fibrillation ( AF ) . Whether it is related to the procedure or to pre-existing heart disease remains unclear . METHODS All patients who had radiofrequency catheter ablation of the AV node and pacemaker implantation for rate control of medically refractory AF were identified retrospectively and observed prospect ively . All patients with sudden death after ablation were identified . The relationship between the procedure and sudden death was defined on the basis of the time between the two as " likely , " " possibly " or " unlikely . " RESULTS Of 334 consecutive patients with AF who underwent AV node ablation  , nine had sudden death after the ablation . Four patients ( 1.2 % ) had sudden death likely related to the procedure : in 3 patients , arrest occurred within 48 h after the procedure ; in one patient , arrest occurred four days after the procedure . In three other patients ( 0.9 % ) , sudden death was possibly related to the procedure because the event occurred within three months afterward . The remaining two deaths were unrelated to the procedure . Diabetes , New York Heart Association functional class ( > or = II ) , preprocedure ventricular arrhythmia , mitral or aortic stenosis , aortic regurgitation and chronic obstructive pulmonary disease were independent predictors for sudden death . CONCLUSIONS Sudden death likely or possibly related to catheter ablation occurred in 7 of 334 patients ( 2.1 % ) . Risk of sudden death is highest within two days after the procedure BACKGROUND Cardiac-resynchronization therapy ( CRT ) benefits patients with left ventricular systolic dysfunction and a wide QRS complex . Most of these patients are c and i date s for an implantable cardioverter-defibrillator ( ICD ) . We evaluated whether adding CRT to an ICD and optimal medical therapy might reduce mortality and morbidity among such patients . METHODS We r and omly assigned patients with New York Heart Association ( NYHA ) class II or III heart failure , a left ventricular ejection fraction of 30 % or less , and an intrinsic QRS duration of 120 msec or more or a paced QRS duration of 200 msec or more to receive either an ICD alone or an ICD plus CRT . The primary outcome was death from any cause or hospitalization for heart failure . RESULTS We followed 1798 patients for a mean of 40 months . The primary outcome occurred in 297 of 894 patients ( 33.2 % ) in the ICD-CRT group and 364 of 904 patients ( 40.3 % ) in the ICD group ( hazard ratio in the ICD-CRT group , 0.75 ; 95 % confidence interval [ CI ] , 0.64 to 0.87 ; P<0.001 ) . In the ICD-CRT group , 186 patients died , as compared with 236 in the ICD group ( hazard ratio , 0.75 ; 95 % CI , 0.62 to 0.91 ; P = 0.003 ) , and 174 patients were hospitalized for heart failure , as compared with 236 in the ICD group ( hazard ratio , 0.68 ; 95 % CI , 0.56 to 0.83 ; P<0.001 ) . However , at 30 days after device implantation , adverse events had occurred in 124 patients in the ICD-CRT group , as compared with 58 in the ICD group ( P<0.001 ) . CONCLUSIONS Among patients with NYHA class II or III heart failure , a wide QRS complex , and left ventricular systolic dysfunction , the addition of CRT to an ICD reduced rates of death and hospitalization for heart failure . This improvement was accompanied by more adverse events . ( Funded by the Canadian Institutes of Health Research and Medtronic of Canada ; Clinical Trials.gov number , NCT00251251 . ) OBJECTIVES We sought to investigate the effect of intrinsic conduction over the right bundle on the maximum rate of left ventricular pressure rise ( LVdP/dt(max ) ) during left ventricular ( LV ) pacing compared to biventricular ( BiV ) pacing . BACKGROUND Simultaneous BiV pacing and LV pacing both improve LV function in patients with heart failure and LV asynchrony . We studied the hemodynamic effect of intrinsic conduction leading to ventricular fusion during LV pacing . METHODS In 34 patients with New York Heart Association functional class III or IV , sinus rhythm with normal atrioventricular ( AV ) conduction , left bundle branch block , QRS > 130 ms , and optimal medical therapy , LVdP/dt(max ) was measured invasively during LV and simultaneous BiV pacing . The AV interval was varied in four steps starting ( AV1 ) with an AV interval 40 ms shorter than the intrinsic PQ time and decreased with 25 % for each step . RESULTS At AV1 , LVdP/dt(max ) was 996 + /- 194 mm Hg/s for LV pacing and 960 + /- 200 mm Hg/s for BiV pacing ( p = 0.0009 ) , with all patients showing ventricular fusion during LV pacing . At AV2 , 21 patients had ventricular fusion with a LVdP/dt(max ) of 983 + /- 213 mm Hg/s and 957 + /- 202 mm Hg/s for LV and BiV pacing , respectively . In the remaining 13 patients without fusion these values were 919 + /- 164 mm Hg/s and 957 + /- 174 mm Hg/s , respectively . The difference between LV and BiV at AV2 is significantly higher when fusion is present ( p = 0.01 ) . CONCLUSIONS The LVdP/dt(max ) is higher in LV than in BiV pacing provided that LV pacing is associated with ventricular fusion caused by intrinsic activation Aim : Recently , digoxin use has been found to associate with higher mortality . Yet , potential mechanisms by which digoxin use increases mortality remain unclear . Increased arrhythmogenicity from digoxin use is one possibility . Thus , we aim ed to evaluate the relation between digoxin and shock events in patients with implantable cardioverter defibrillators ( ICDs ) . Methods : We performed a retrospective chart review of all patients with ICDs and at least 1 device interrogation at our institution between January 1 , 2012 , and January 1 , 2015 . We aim ed to cover 1 year of interrogation period . Patients with heart failure , atrial fibrillation , or both were included in the analysis . Patients were divided into 2 groups based on digoxin use , defined as use of digoxin for any period of time during ICD interrogation period . Incidence of ICD shock events and electrical storms and hospitalizations were compared between the 2 groups . Results : The study included 202 patients . Of those , 55 patients were on digoxin and 147 were not on digoxin .  Patients on digoxin were more likely to receive ICD shocks ( odds ratio [ OR ] = 2.5 , 95 % confidence interval [ 95 % CI ] = 1.01 - 6.18 , P = .04 ) and have increased risk of electrical storms ( P = .02 ) . Moreover , total hospitalizations were higher in digoxin users ( P = .02 ) . Multivariate logistic regression analysis also showed that digoxin use was an independent predictor of shock events ( OR = 4.07 , 95 % CI = 1.43 - 11.58 , P = .009 ) . Conclusion : Digoxin is associated with increased shock events and electrical storms in patients with ICDs ; however , large r and omized controlled studies are needed to confirm our findings
target: Conclusion The results of our meta- analysis suggest that AF was associated with decreased CRT benefits in patients with HF .
  CRT , however , benefits patients with AF with AVJ ablation
background: Background Cardiac resynchronisation therapy ( CRT ) is beneficial in selected patients with heart failure ( HF ) in normal sinus rhythm ( NSR ) .