Atrioventricular junction ablation in patients with atrial fibrillation treated with cardiac resynchronization therapy: Positive impact on ventricular arrhythmias, implantable cardioverter-defibrillator therapies and hospitalizations

Aims: We sought to determine whether atrioventricular junction ablation (AVJA) in patients with cardiac resynchronization therapy (CRT) implantable cardioverter-defibrillator (ICD) and with permanent atrial fibrillation (AF) has a positive impact on ICD shocks and hospitalizations compared with rate-slowing drugs. Methods and results: This is a pooled analysis of data from 179 international centres participating in two randomized trials and one prospective observational research. The co-primary endpoints were all-cause ICD shocks and all-cause hospitalizations. Out of 3358 CRT-ICD patients (2720 male, 66.6years), 2694 (80%) were in sinus rhythm (SR) and 664 (20%) had permanent AF-262 (8%) treated with AVJA (AF+AVJA) and 402 (12%) treated with rate-slowing drugs (AF+Drugs). Median follow-up was 18months. The mean (95% confidence intervals) annual rate of all-cause ICD shocks per 100 patient years was 8.0 (5.3-11.9) in AF+AVJA, 43.6 (37.7-50.4) in AF+Drugs, and 34.4 (32.5-36.5) in SR patients, resulting in incidence rate ratio (IRR) reductions of 0.18 (0.10-0.32) for AF+AVJA vs. AF+Drugs (P<0.001) and 0.48 (0.35-0.66) for AF+AVJA vs. SR (P<0.001). These reductions were driven by significant reductions in both appropriate ICD shocks [IRR 0.23 (0.13-0.40), P<0.001, vs. AF+Drugs] and inappropriate ICD shocks [IRR 0.09 (0.04-0.21), P<0.001, vs. AF+Drugs]. Annual rate of all-cause hospitalizations was significantly lower in AF+AVJA vs. AF+Drugs [IRR 0.57 (0.41-0.79), P<0.001] and SR [IRR 0.85 (073-0.98), P=0.027]. Conclusion: In AF patients treated with CRT, AVJA results in a lower incidence and burden of all-cause, appropriate and inappropriate ICD shocks, as well as to fewer all-cause and heart failure hospitalizations.