AV junction ablation and cardiac resynchronization for patients with permanent atrial fibrillation and narrow QRS: the APAF-CRT mortality trial

M. Brignole*, F. Pentimalli, P. Palmisano, M. Landolina, F. Quartieri, E. Occhetta, L. Calo, G. Mascia, L. Mont, K. Vernooy, V. van Dijk, C. Allaart, L. Fauchier, M. Gasparini, G. Parati, D. Soranna, M. Rienstra, I.C. Van Gelder, APAF-CRT Trial Investigators

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review


Aims In patients with atrial fibrillation (AF) and heart failure (HF), strict and regular rate control with atrioventricular junction ablation and biventricular pacemaker (Ablation + CRT) has been shown to be superior to pharmacological rate control in reducing HF hospitalizations. However, whether it also improves survival is unknown.Methods and results In this international, open-label, blinded outcome trial, we randomly assigned patients with severely symptomatic permanent AF >6 months, narrow QRS (<= 110 ms) and at least one HF hospitalization in the previous year to Ablation + CRT or to pharmacological rate control. We hypothesized that Ablation + CRT is superior in reducing the primary endpoint of all-cause mortality. A total of 133 patients were randomized. The mean age was 73 +/- 10 years, and 62 (47%) were females. The trial was stopped for efficacy at interim analysis after a median of 29 months of follow-up per patient. The primary endpoint occurred in 7 patients (11%) in the Ablation + CRT arm and in 20 patients (29%) in the Drug arm [hazard ratio (HR) 0.26, 95% confidence interval (CI) 0.10-0.65; P= 0.004]. The estimated death rates at 2 years were 5% and 21%, respectively; at 4 years, 14% and 41%. The benefit of Ablation + CRT of all-cause mortality was similar in patients with ejection fraction (EF) <= 35% and in those with >35%. The secondary endpoint combining all-cause mortality or HF hospitalization was significantly lower in the Ablation + CRT arm [18 (29%) vs. 36 (51%); HR 0.40, 95% CI 0.22-0.73; P = 0.002].Conclusions Ablation + CRT was superior to pharmacological therapy in reducing mortality in patients with permanent AF and narrow QRS who were hospitalized for HF, irrespective of their baseline EF.[GRAPHICS].
Original languageEnglish
Pages (from-to)4731-4739
Number of pages9
JournalEuropean Heart Journal
Issue number46
Publication statusPublished - 7 Dec 2021


  • Atrial fibrillation
  • Heart failure
  • Cardiac resynchronization therapy
  • Catheter ablation
  • AV node ablation
  • QRS width

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