Cardiac resynchronization therapy in atrial fibrillation
- Leslie A Saxon, MD
Leslie A Saxon, MD
- Professor of Medicine
- University of Southern California
- Section Editors
- Wilson S Colucci, MD
Wilson S Colucci, MD
- Section Editor — Heart Failure
- Professor of Medicine
- Boston University School of Medicine
- Bradley P Knight, MD, FACC
Bradley P Knight, MD, FACC
- Section Editor — Cardiac Arrhythmias
- Professor of Medicine
- Feinberg School of Medicine, Northwestern University
In patients with significant dyssynchrony due to intrinsic conduction disease, cardiac resynchronization therapy (CRT) with biventricular pacing can improve ventricular synchrony. This is accomplished with an additional pacemaker lead implanted on the lateral left ventricle via a coronary vein. Among selected patients with heart failure (HF) who are in sinus rhythm, CRT improves cardiac performance, symptoms, and overall survival. (See "Cardiac resynchronization therapy in heart failure: Indications".)
The prevalence of atrial fibrillation (AF) in patients with HF varies with severity, ranging from 5 percent in patients with New York Heart Association (NYHA) functional class I HF to 40 percent in patients with NYHA class IV HF (table 1) .
The use of CRT in patients with AF will be reviewed here. The general use of CRT in patients in sinus rhythm and the rationale for and mechanisms of benefit of CRT are discussed separately. (See "Cardiac resynchronization therapy in heart failure: Indications" and "Rationale for and mechanisms of benefit of cardiac resynchronization therapy".)
CLINICAL SETTINGS FOR USE
Among patients with chronic atrial fibrillation (AF), cardiac resynchronization therapy (CRT) may be considered in three overlapping clinical settings: in the setting of atrioventricular (AV) block due to conduction system disease, following atrioventricular node ablation, and with systolic heart failure (HF).
Atrioventricular block — Patients requiring pacemaker therapy for AV block caused by conduction system disease may avoid the negative effects of dyssynchrony that can be induced by right ventricular (RV) pacing via CRT. Evidence supporting this approach in patients with AF or sinus rhythm is discussed below. This clinical setting overlaps with the HF setting since the study population included patients with AV block with systolic dysfunction and HF. (See 'Patients requiring a pacemaker for AV block' below.)
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- CLINICAL SETTINGS FOR USE
- Atrioventricular block
- Atrioventricular node ablation
- Heart failure
- OUR APPROACH
- Indications for CRT in patients with AF
- Practical considerations
- EVIDENCE OF CRT BENEFIT IN PATIENTS WITH ATRIAL FIBRILLATION
- Patients requiring a pacemaker for AV block
- Patients who have undergone AV node ablation
- Patients with heart failure
- - Role of AV node ablation in patients with HF and AF
- Mixed patient population
- COMPARISON WITH PULMONARY VEIN ISOLATION
- EFFECT OF CRT ON ATRIAL FIBRILLATION
- MAJOR SOCIETY GUIDELINES
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS