Necessity and benefit of an additional atrial lead in patients with atrial fibrillation and Cardiac Resynchronization Therapy – a single center experience

Introduction: The necessity and benefit of an additional atrial lead in patients with permanent versus non-permanent atrial fibrillation (AF) in need of Cardiac Resynchronization Therapy (CRT) is not well investigated yet. In contrast, numerous trials show benefit for patients with AF in combination with atrio-ventricular node ablation. We retrospectively analyzed the results of our patients who regularly received an atrial lead in case of AF.

Methods: In a retrospective single center investigation we observed 400 CRT implantations from January 2008 till June 2010. 184 (46%) of those patients had documented AF. These patients were classified in two groups. First, non-permanent AF group (Np-AF) including paroxysmal, spontaneously ending AF within 7 days and persistent AF in case of not spontaneously ending and more than 7 days persisting arrhythmia. Second group encloses permanent AF (Pm-AF) in case of continuing arrhythmia for more than one year. We compared baseline characteristics, procedural parameters and follow-up data within the first year after implantation.

Results: Permanent AF (Pm-AF) was detected in 96 (52.2%) patients while 47.8% had paroxysmal or persistent AF (Np-AF). Pm-AF patients were older (70.39 vs. 66.87 years, p < 0.05) and more likely to receive a CRT pacemaker (25% vs. 6.8%, p < 0.05). Moreover, in significantly more patients of Pm-AF group AV node ablation has been performed (17.7% vs. 7%, p < 0.05). In contrast, all patients in Np-AF group sustained an atrial leads compared to 80% in the Pm-AF group (p < 0.05). At implantation time 54.5% of patients in Np-AF group were in sinus rhythm (SR) while certainly all patients in Pm-AF group showed AF (p < 0.05). Three months after implantation the majority of patients in Np-AF group still illustrates SR with DDD pacing (79.1% vs. 13.6%, p < 0.05). Furthermore, 75.5% of patients in Np-AF group still remains in SR by DDD pacing in one-year follow-up compared to Pm-AF group where only 12.3% (p < 0.05) exhibits SR.

Conclusion: Our investigation shows that patients in the Np-AF group benefits by an additional atrial lead and tend to stay in SR aided by DDD pacing. Nevertheless, about 12% of the Pm-AF group also avails from DDD pacing by an atrial lead. Based on these results we propose that patients with Np-AF should receive an additional atrial lead whereas patients with Pm-AF should be carefully selected.