Comparison of survival for cardiac resynchronization therapy in atrial fibrillation patients with or without atrio-ventricular junction ablation and patients in sinus rhythm: a systematic review and network meta-analysis

  • Yangjing Xue
  • Jinsheng Wang
  • Jiaoni Wang
  • Saroj Thapa
  • Kaiyu Huang
  • Yangpei Peng
  • Lu Qian
  • Jiwu LiEmail author
  • Kangting JiEmail author


Cardiac resynchronization therapy (CRT) has been established to improve prognosis for patients with heart failure and SR. Whether the benefit observed with CRT on survival was similar in AF patients receiving atrio-ventricular junction ablation (AVJA) or not and patients in SR remains uncertain. The primary purpose of this study was to comprehensively evaluate the impact of CRT on the outcome of survival in atrial fibrillation (AF) patients with or without AVJA and patients in sinus rhythm (SR). Medline, Embase, and the Cochrane Library were searched for inception through June 31, 2018. Two reviewers independently evaluated and extracted data from 4 studies, including a total of 7896 CRT recipients, composed of 554 AF with AVJA (CRT+AF+AVJA), 1071 AF without AVJA (CRT+AF-AVJA), and 6244 SR (CRT+SR). The benefit on survival was comparable between CRT+AF+AVJA and CRT+SR (HR = 1.00; 95% CI, 0.73–1.40). CRT+AF+AVJA and CRT+SR both were associated with significantly higher survival compared with CRT+AF-AVJA, with hazard ratio of 0.64 (95% CI, 0.46–0.91) and 0.63 (95% CI, 0.53–0.75), respectively. The survival benefit was similar for patients with CRT+AF+AVJA and CRT+SR, while it was 36–37% high as compared to CRT+AF-AVJA. Whether aggressive intervention with AVJA in AF should be routinely combined with CRT despite rate-slowing drug treatment is helpful deserves further studies.


Atrial fibrillation Cardiac resynchronization therapy Atrio-ventricular junction ablation Heart failure Survival 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Supplementary material

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  1. 1.
    Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Drazner MH et al (2013) 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 62:e147–e239CrossRefGoogle Scholar
  2. 2.
    Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JG, Coats AJ, Falk V, González-Juanatey JR, Harjola VP, Jankowska EA, Jessup M, Linde C, Nihoyannopoulos P, Parissis JT, Pieske B, Riley JP, Rosano GMC, Ruilope LM, Ruschitzka F, Rutten FH, van der Meer P, ESC Scientific Document Group (2016) 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J 37:2129–2200CrossRefGoogle Scholar
  3. 3.
    Tracy CM, Epstein AE, Darbar D, DiMarco JP, Dunbar SB, Estes NA 3rd et al (2012) 2012 ACCF/AHA/HRS focused update of the 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. [corrected]. Circulation 126:1784–1800CrossRefGoogle Scholar
  4. 4.
    Brignole M, Auricchio A, Baron-Esquivias G, Bordachar P, Boriani G, Breithardt OA, Cleland J, Deharo JC, Delgado V, Elliott PM, Gorenek B, Israel CW, Leclercq C, Linde C, Mont L, Padeletti L, Sutton R, Vardas PE, ESC Committee for Practice Guidelines (CPG), Zamorano JL, Achenbach S, Baumgartner H, Bax JJ, Bueno H, Dean V, Deaton C, Erol C, Fagard R, Ferrari R, Hasdai D, Hoes AW, Kirchhof P, Knuuti J, Kolh P, Lancellotti P, Linhart A, Nihoyannopoulos P, Piepoli MF, Ponikowski P, Sirnes PA, Tamargo JL, Tendera M, Torbicki A, Wijns W, Windecker S, Document Reviewers, Kirchhof P, Blomstrom-Lundqvist C, Badano LP, Aliyev F, Bänsch D, Baumgartner H, Bsata W, Buser P, Charron P, Daubert JC, Dobreanu D, Faerestrand S, Hasdai D, Hoes AW, le Heuzey JY, Mavrakis H, McDonagh T, Merino JL, Nawar MM, Nielsen JC, Pieske B, Poposka L, Ruschitzka F, Tendera M, van Gelder I, Wilson CM (2013) 2013 ESC guidelines on cardiac pacing and cardiac resynchronization therapy: the Task Force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA). Eur Heart J 34:2281–2329CrossRefGoogle Scholar
  5. 5.
    Maisel WH, Stevenson LW (2003) Atrial fibrillation in heart failure: epidemiology, pathophysiology, and rationale for therapy. Am J Cardiol 91:2D–8DCrossRefGoogle Scholar
  6. 6.
    Koplan BA, Kaplan AJ, Weiner S, Jones PW, Seth M, Christman SA (2009) Heart failure decompensation and all-cause mortality in relation to percent biventricular pacing in patients with heart failure: is a goal of 100% biventricular pacing necessary? J Am Coll Cardiol 53:355–360CrossRefGoogle Scholar
  7. 7.
    Hayes DL, Boehmer JP, Day JD, Gilliam FR 3rd, Heidenreich PA, Seth M et al (2011) Cardiac resynchronization therapy and the relationship of percent biventricular pacing to symptoms and survival. Heart Rhythm 8:1469–1475CrossRefGoogle Scholar
  8. 8.
    Ganesan AN, Brooks AG, Roberts-Thomson KC, Lau DH, Kalman JM, Sanders P (2012) Role of AV nodal ablation in cardiac resynchronization in patients with coexistent atrial fibrillation and heart failure a systematic review. J Am Coll Cardiol 59:719–726CrossRefGoogle Scholar
  9. 9.
    Lopes C, Pereira T, Barra S (2014) Cardiac resynchronization therapy in patients with atrial fibrillation: a meta-analysis. Rev Port Cardiol 33:717–725CrossRefGoogle Scholar
  10. 10.
    Yin J, Hu H, Wang Y, Xue M, Li X, Cheng W, Li X, Yan S (2014) Effects of atrioventricular nodal ablation on permanent atrial fibrillation patients with cardiac resynchronization therapy: a systematic review and meta-analysis. Clin Cardiol 37:707–715CrossRefGoogle Scholar
  11. 11.
    Delnoy PP, Ottervanger JP, Luttikhuis HO, Elvan A, Misier AR, Beukema WP et al (2007) Comparison of usefulness of cardiac resynchronization therapy in patients with atrial fibrillation and heart failure versus patients with sinus rhythm and heart failure. Am J Cardiol 99:1252–1257CrossRefGoogle Scholar
  12. 12.
    Khadjooi K, Foley PW, Chalil S, Anthony J, Smith RE, Frenneaux MP et al (2008) Long-term effects of cardiac resynchronisation therapy in patients with atrial fibrillation. Heart 94:879–883CrossRefGoogle Scholar
  13. 13.
    Upadhyay GA, Choudhry NK, Auricchio A, Ruskin J, Singh JP (2008) Cardiac resynchronization in patients with atrial fibrillation: a meta-analysis of prospective cohort studies. J Am Coll Cardiol 52:1239–1246CrossRefGoogle Scholar
  14. 14.
    Tierney JF, Stewart LA, Ghersi D, Burdett S, Sydes MR (2007) Practical methods for incorporating summary time-to-event data into meta-analysis. Trials 8:16CrossRefGoogle Scholar
  15. 15.
    DerSimonian R, Laird N (1986) Meta-analysis in clinical trials. Control Clin Trials 7:177–188CrossRefGoogle Scholar
  16. 16.
    Dong K, Shen W-K, Powell BD, Dong Y-X, Rea RF, Friedman PA, Hodge DO, Wiste HJ, Webster T, Hayes DL, Cha YM (2010) Atrioventricular nodal ablation predicts survival benefit in patients with atrial fibrillation receiving cardiac resynchronization therapy. Heart Rhythm 7:1240–1245CrossRefGoogle Scholar
  17. 17.
    Ferreira AM, Adragao P, Cavaco DM, Candeias R, Morgado FB, Santos KR et al (2008) Benefit of cardiac resynchronization therapy in atrial fibrillation patients vs. patients in sinus rhythm: the role of atrioventricular junction ablation. Europace 10:809–815CrossRefGoogle Scholar
  18. 18.
    Gasparini M, Auricchio A, Metra M, Regoli F, Fantoni C, Lamp B, Curnis A, Vogt J, Klersy C, for the Multicentre Longitudinal Observational Study (MILOS) Group (2008) Long-term survival in patients undergoing cardiac resynchronization therapy: the importance of performing atrio-ventricular junction ablation in patients with permanent atrial fibrillation. Eur Heart J 29:1644–1652CrossRefGoogle Scholar
  19. 19.
    Gasparini M, Leclercq C, Lunati M, Landolina M, Auricchio A, Santini M, Boriani G, Lamp B, Proclemer A, Curnis A, Klersy C, Leyva F (2013) Cardiac resynchronization therapy in patients with atrial fibrillation: the CERTIFY study (Cardiac Resynchronization Therapy in Atrial Fibrillation Patients Multinational Registry). JACC Heart Fail 1:500–507CrossRefGoogle Scholar
  20. 20.
    Jedrzejczyk-Patej E, Lenarczyk R, Pruszkowska P, Kowalski O, Mazurek M, Sokal A et al (2014) Long-term outcomes of cardiac resynchronization therapy are worse in patients who require atrioventricular junction ablation for atrial fibrillation than in those with sinus rhythm. Cardiol J 21:309–315CrossRefGoogle Scholar
  21. 21.
    Kuznetsov V, Vinogradova T, Enina T, Kolunin G, Kharats V, Krinochkin D, Gorbatenko E (2014) Influence of atrioventricular junction ablation on survival of patients with congestive heart failure and atrial fibrillation receiving cardiac resynchronisation therapy in real clinical practice. Glob Heart 9:e42–ee3CrossRefGoogle Scholar
  22. 22.
    Gasparini M, Auricchio A, Regoli F, Fantoni C, Kawabata M, Galimberti P, Pini D, Ceriotti C, Gronda E, Klersy C, Fratini S, Klein HH (2006) Four-year efficacy of cardiac resynchronization therapy on exercise tolerance and disease progression: the importance of performing atrioventricular junction ablation in patients with atrial fibrillation. J Am Coll Cardiol 48:734–743CrossRefGoogle Scholar
  23. 23.
    Wells GA, Shea B, O'Connell D, Peterson J, Welch V, Losos M, Tugwell P (2012) The Newcastle-Ottawa scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Available at Accessed 1 June 2018
  24. 24.
    Wilton SB, Leung AA, Ghali WA, Faris P, Exner DV (2011) Outcomes of cardiac resynchronization therapy in patients with versus those without atrial fibrillation: a systematic review and meta-analysis. Heart Rhythm 8:1088–1094CrossRefGoogle Scholar
  25. 25.
    Kamath GS, Cotiga D, Koneru JN, Arshad A, Pierce W, Aziz EF, Mandava A, Mittal S, Steinberg JS (2009) The utility of 12-lead Holter monitoring in patients with permanent atrial fibrillation for the identification of nonresponders after cardiac resynchronization therapy. J Am Coll Cardiol 53:1050–1055CrossRefGoogle Scholar
  26. 26.
    Barold SS, Herweg B (2015) Cardiac resynchronization in patients with atrial fibrillation. J Atr Fibrillation 8:1383Google Scholar
  27. 27.
    Wood MA, Brown-Mahoney C, Kay GN, Ellenbogen KA (2000) Clinical outcomes after ablation and pacing therapy for atrial fibrillation: a meta-analysis. Circulation 101:1138–1144CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Yangjing Xue
    • 1
  • Jinsheng Wang
    • 1
  • Jiaoni Wang
    • 1
  • Saroj Thapa
    • 1
  • Kaiyu Huang
    • 1
  • Yangpei Peng
    • 1
  • Lu Qian
    • 1
  • Jiwu Li
    • 1
    Email author
  • Kangting Ji
    • 1
    Email author
  1. 1.Department of Cardiology, the Second Affiliated Hospital and Yuying Children’s HospitalWenzhou Medical UniversityWenzhouChina

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