Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Australia.
J Am Coll Cardiol. 2012 Feb 21;59(8):719-26. doi: 10.1016/j.jacc.2011.10.891.
The aim of this study was to systematically review the medical literature to evaluate the impact of AV nodal ablation in patients with heart failure and coexistent atrial fibrillation (AF) receiving cardiac resynchronization therapy (CRT).
CRT has a substantial evidence base in patients in sinus rhythm with significant systolic dysfunction, symptomatic heart failure, and prolonged QRS duration. The role of CRT is less well established in AF patients with coexistent heart failure. AV nodal ablation has recently been suggested to improve outcomes in this group.
Electronic databases and reference lists through September 15, 2010, were searched. Two reviewers independently evaluated citation titles, abstracts, and articles. Studies reporting the outcomes after AV nodal ablation in patients with AF undergoing CRT for symptomatic heart failure and left ventricular dyssynchrony were selected. Data were extracted from 6 studies, including 768 CRT-AF patients, composed of 339 patients who underwent AV nodal ablation and 429 treated with medical therapy aimed at rate control alone.
AV nodal ablation in CRT-AF patients was associated with significant reductions in all-cause mortality (risk ratio: 0.42 [95% confidence interval: 0.26 to 0.68]), cardiovascular mortality (risk ratio: 0.44 [95% confidence interval: 0.24 to 0.81]), and improvement in mean New York Heart Association functional class (risk ratio: -0.52 [95% confidence interval: -0.87 to -0.17]).
AV nodal ablation was associated with a substantial reduction in all-cause mortality and cardiovascular mortality and with improvements in New York Heart Association functional class compared with medical therapy in CRT-AF patients. Randomized controlled trials are warranted to confirm the efficacy and safety of AV nodal ablation in this patient population.
本研究旨在系统回顾医学文献，评估房室结消融对心力衰竭合并心房颤动（AF）且接受心脏再同步治疗（CRT）的患者的影响。
CRT 在窦性心律、显著收缩功能障碍、有症状心力衰竭和 QRS 持续时间延长的患者中有大量的证据支持。在 AF 合并心力衰竭的患者中，CRT 的作用尚不确定。房室结消融最近被建议改善这组患者的预后。
检索电子数据库和参考文献列表，截止日期为 2010 年 9 月 15 日。两位评审员独立评估引用标题、摘要和文章。选择报告 AF 患者接受 CRT 治疗有症状心力衰竭和左心室不同步且行房室结消融后结局的研究。从 6 项研究中提取数据，包括 768 例 CRT-AF 患者，其中 339 例患者行房室结消融，429 例患者接受单纯控制心率的药物治疗。
CRT-AF 患者行房室结消融与全因死亡率显著降低相关（风险比：0.42 [95%置信区间：0.26 至 0.68]）、心血管死亡率降低（风险比：0.44 [95%置信区间：0.24 至 0.81]）和平均纽约心脏协会功能分级改善（风险比：-0.52 [95%置信区间：-0.87 至 -0.17]）。
与药物治疗相比，房室结消融在 CRT-AF 患者中与全因死亡率和心血管死亡率的显著降低以及纽约心脏协会功能分级的改善相关。需要进行随机对照试验来证实房室结消融在这一患者人群中的疗效和安全性。
