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

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.