By Ahmed El-Medany
Presented by Professor Michele Brignole, San Luca Hospital, Milan, APAF-CRT was a two-phase trial in individuals with severely symptomatic atrial fibrillation (AF) with narrow QRS. The first phase, focused on morbidity and showed that AV junction ablation and cardiac resynchronisation therapy (CRT) reduced hospitalisation due to heart failure and improved heart failure symptoms compared with pharmacological rate control following two years of follow-up. Results of the second phase, presented at ESC 2021, focused on mortality. In a larger population with a longer follow-up, the trial assessed whether AV junction ablation and biventricular pacing is superior to pharmacological rate control therapy in reducing all-cause mortality.
APAF-CRT was a multicentre, prospective, randomised, open-label trial with a blinded outcome. Patients were enrolled with the following inclusion criteria: severely symptomatic permanent AF (> 6 months) considered unsuitable for AF ablation or in whom AF ablation had failed; narrow QRS (≤110 ms); and previous hospitalisation for heart failure in the previous year.
133 participants were randomly assigned in a 1:1 ratio to AV junction ablation and biventricular pacing (ablation+CRT arm) or optimal pharmacological rate control therapy (drug arm).
The primary endpoint of death from any cause occurred in 7 (11%) and 20 (29%) of participants in the ablation+CRT arm and drug arm, respectively (hazard ratio [HR] 0.26; 95% confidence interval [CI] 0.10–0.65; p=0.004). The estimated death rates at 4 years were 14% and 41% in the ablation+CRT and drug arms, respectively. At four years, the relative and absolute risk reductions were 74% and 27%, respectively; and the number needed to treat was 3.7.
Principal investigator Professor Michele Brignole concluded: ‘The improvement in survival shown by the APAF-CRT trial supports ablation plus CRT as a first line therapy in patients with permanent AF, narrow QRS and previous hospitalisation for heart failure.’
Source: Brignole M, et al. APAF-CRT. Presented at: European Society of Cardiology Congress; Aug. 27-30, 2021 (virtual meeting).
Read more here:
Brignole M et al. Benefit of AV junction ablation and cardiac resynchronization therapy on mortality among patients with permanent atrial fibrillation and narrow QRS. The APAF-CRT Long-Term Outcome Randomized Clinical Trial. Eur Heart J. Link will go live on publication: https://academic.oup.com/eurheartj/article-lookup/doi/10.1093/eurheartj/ehab569
Brignole M, Pokushalov E, Pentimalli F, et al. A randomized controlled trial of atrioventricular junction ablation and cardiac resynchronization therapy in patients with permanent atrial fibrillation and narrow QRS. Eur Heart J. 2018;39:3999–4008.
Figure 1 (Top): Taken from the ESC Congress 2021. Visual abstract of the APAF-CRT trial.