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Feasibility and efficacy of electrical cardioversion after cardiac resynchronization implantation in patients with permanent atrial fibrillation

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Journal of Interventional Cardiac Electrophysiology Aims and scope Submit manuscript

Abstract

Purpose

Patients with permanent atrial fibrillation (AF) who undergo cardiac resynchronization therapy (CRT) may spontaneously recover sinus rhythm during follow-up. We tested the feasibility and efficacy of electrical cardioversion attempted after 3 months of CRT in patients with permanent AF and measured the long-term maintenance of sinus rhythm.

Methods

Twenty-eight consecutive patients with permanent AF in whom CRT defibrillators had been implanted were scheduled for internal electrical cardioversion after 3 months (group A) and were compared with a control group of 27 patients (group B).

Results

In group A, 22 patients (79 %) were eligible for cardioversion; sinus rhythm was restored in 18 (82 %) of these, with no procedural complications. After 12 months, 16 patients (58 %) in group A were in sinus rhythm, compared with one group B patient who spontaneously recovered sinus rhythm (4 %, p < 0.001). On 12-month evaluation, ejection fraction had improved in both groups, but a reduction in left ventricular end-systolic volume was recorded only in group A patients (p = 0.018 versus baseline).

Conclusions

In patients with permanent AF, the rhythm control strategy consisting of internal cardioversion, performed by means of the implanted cardioverter–defibrillator after 3 months of CRT, was associated with a high rate of sinus rhythm resumption on long-term follow-up and with a better echocardiographic response to CRT than that seen in patients treated according to a rate control strategy.

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Disclosures

Carmine Ciardiello is an employee of Boston Scientific, Inc. No other conflicts of interest exist.

Author information

Authors and Affiliations

  1. Casa di Cura San Michele, Maddaloni, Caserta, Italy

    Vincenzo La Rocca & Antonio De Simone

  2. Azienda Ospedaliera Monaldi, Naples, Italy

    Antonio D’Onofrio, Filippo Vecchione, Stefano De Vivo, Ciro Cavallaro & Valter Bianchi

  3. Clinica Mediterranea, Naples, Italy

    Pietro Turco, Giuseppe Stabile, Assunta Iuliano & Alessia Agresta

  4. Casa di Cura Montevergine, Mercogliano, Avellino, Italia

    Francesco Solimene & Natale Marrazzo

  5. Boston Scientific Italy, Milan, Italy

    Carmine Ciardiello

  6. Laboratorio di Elettrofisiologia, Clinica Mediterranea, Via Orazio 2, 80100, Naples, Italy

    Giuseppe Stabile

Authors
  1. Pietro Turco
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  2. Antonio D’Onofrio
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  3. Giuseppe Stabile
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  4. Francesco Solimene
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  5. Vincenzo La Rocca
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  7. Assunta Iuliano
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  9. Stefano De Vivo
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  10. Ciro Cavallaro
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  13. Carmine Ciardiello
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  14. Antonio De Simone
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Corresponding author

Correspondence to Giuseppe Stabile.

Additional information

Editorial Commentary

Patients with permanent atrial fibrillation can and do spontaneously achieve sinus rhythm after cardiac resynchronization therapy (CRT), likely due to ventricular and atrial reverse remodeling; this occurs in a minority of patients. This study looked at 28 patients with systolic dysfunction who were functional Class III-IV, who had permanent atrial fibrillation and who received CRT; at 3 months, after pre-treatment with amiodarone, 22/28 were internally cardioverted to sinus rhythm, and the maintenance of sinus rhythm over a specified time period was assessed . A control group consisted of 27 patients not cardioverted who achieved spontaneous sinus rhythm over the followup period. Successful cardioversion to sinus rhythm was achieved in 82 % of these heart failure patients, and the majority (58 %) maintained sinus rhythm at one year, compared to a single patient who achieved sinus rhythm spontaneously.

The study results indicate that electrical cardioversion in CRT patients may well be warranted, as sinus rhythm can be achieved and maintained and is associated with substantially improved echocardiographic outcomes. Although ventricular remodeling after CRT may take up to 6 months to be appreciated (at least echocardiographically) , and thus cardioversion at 3 months may be premature in judging the overall effects of this procedure (achievement and maintenance of sinus rhythm), spontaneous resumption of sinus rhythm, if it occurs, takes on average about 4 months to occur and thus an earlier cardioversion attempt could result in optimization of further management strategy (rhythm vs. rate ‘control’) in individual patients.

This is a provocative study which could potentially change our approach to patients with ‘permanent’ AF who undergo CRT, and which, if confirmed in larger trials, could change even the definition of ‘permanent’ AF itself.

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Turco, P., D’Onofrio, A., Stabile, G. et al. Feasibility and efficacy of electrical cardioversion after cardiac resynchronization implantation in patients with permanent atrial fibrillation. J Interv Card Electrophysiol 35, 331–336 (2012). https://doi.org/10.1007/s10840-012-9713-2

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  • DOI: https://doi.org/10.1007/s10840-012-9713-2

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