Atrioventricular junction ablation combined with either right ventricular pacing or cardiac resynchronization therapy for atrial fibrillation: The need for large-scale randomized trials

BACKGROUND Nonrandomized studies suggest that atrioventricular (AV) junction ablation and pacemaker implantation may improve quality of life, ejection fraction, and exercise tolerance in patients with symptomatic drug-refractory atrial fibrillation. OBJECTIVE The purpose of this study was to determine whether recent randomized trials support the use of AV junction ablation in combination with conventional right ventricular pacemaker therapy or cardiac resynchronization therapy (CRT) in atrial fibrillation. METHODS Meta-analysis of randomized trials comparing AV junction ablation vs drugs or CRT vs right ventricular pacing for atrial fibrillation. RESULTS Six randomized trials with 323 patients compared AV junction ablation vs pharmacologic therapy. The majority of these trials did not individually report a statistically significant improvement in survival, stroke, hospitalization, functional class, atrial fibrillation-associated symptoms, Left ventricular ejection fraction, exercise capacity, healthcare costs, or quality of Life. Overall, all-cause mortality was 3.5% for AV junction ablation patients and 3.3% for controls (relative risk 1.18, 99% confidence interval 0.26-5.22). Three randomized trials with 347 patients compared CRT vs right ventricular pacing in atrial fibrillation. These trials did not individually report a statistically significant improvement in survival, stroke, hospitalization, exercise capacity, or healthcare costs. CRT was associated with a statistically significant improvement in ejection fraction in two of the three trials. Overall, CRT was associated with a trend toward reduced all-cause mortality relative to controls (relative risk 0.51, 99% confidence interval 0.22-1.16). All-cause mortality was 7.1% for CRT patients and 14% for controls. CONCLUSION Limited randomized trial data have been published regarding AV junction ablation in combination with conventional pacemaker therapy or CRT for atrial fibrillation. Large-scale randomized trials are needed to assess the efficacy of these therapies.