[CRT-FORUM] 24E. AF, HF and CRT. Dr. Leyva

[CRT-INFO]

Dear all,
 
Observational data from our group (Khadjooi K, et al. Heart 
2008;94:879-883) suggests that patients in AF benefit to the same degree 
as patients in SR, in terms of symptomatic as well as prognostic 
benefit. Gasparini M et al (J Am Coll Cardiol 2006;48:734-43) propose 
that all patients in AF should receive AV junction ablation. In balance, 
I would recommend that in patients with AF one should implant a CRT 
device and then uptitrate rate-slowing drugs to achieve a %biventricular 
pacing of at least 90%. If the patietns does not improve and 90% pacing 
cannot be achieved, I would then proceed to AV junction ablation. 
Admittedly, Gasparini M et al's data does suggest a prognostic benefit 
from AVJ ablation compared to medical treatment. This requires further 
investigation in a randomised study.
 
 
Dr Francisco Leyva (United Kingdom)
> With the exception of a small substudy of MUSTIC, patients with AF and 
> the usual criteria for CRT have not been included in randomized 
> clinical trials. Some published observational studies suggest a 
> similar benefit for AF patients as for patients with sinus rhythm. 
> However, other studies raise some cautions and suggest that many AF 
> patients do not respond,  possibly due to ineffective pacing, and 
> instead AF patients may require extra-ordinary steps to achieve rate 
> control, including at times AV junction ablation. For these reasons, 
> it is reasonable to implant CRT at present, but keep in mind the 
> caveats described above. Ideally, this population deserves a 
> independent assessment in a randomized clinical trial, not only to 
> prove benefit, but to quantify the frequency and magnitude of benefit, 
> and potential special efforts to achieve clinical response.
>
> Jon Steinberg
>> AF is a major issue in HF patiens and its presence may interfere with 
>> optimal delivery of CRT.  Do you think that up today, this is a clear 
>> indication for implantation or it must be assesed in randomized 
>> clinical trials?
>> Kenneth Woolfe, MD
>> Oakland, Ca
>>
>
>


-- 
Dr. Sergio Dubner
President of Scientific Committee

Dr. Edgardo Schapachnik
President of Steering Committee