Long-term effects of cardiac resynchronisation therapy in patients with atrial fibrillation Cardiac resynchronization therapy in patients with atrial fibrillation: a 2-year follow-up study. Outcomes of cardiac resynchronization therapy in patients with intermittent atrial fibrillation or atrial flutter in the COMPANION trial. Surface electrocardiogram to predict outcome in candidates for cardiac resynchronization therapy: a sub-analysis of the CARE-HF trial. Effects of cardiac resynchronization therapy on long-term quality of life: an analysis from the CArdiac Resynchronisation-Heart Failure (CARE-HF) study. Cardiac resynchronisation therapy in patients with heart failure and a normal QRS duration: the RESPOND study Effect of Cardiac Resynchronization on the Incidence of Atrial Fibrillation in Patients With Severe Heart Failure The CARE-HF study (CArdiac REsynchronisation in Heart Failure study): rationale, design and end-points. Telemonitoring in heart failure patients treated by cardiac resynchronisation therapy with defibrillator (CRT-D): the TELECART Study. Comparison of usefulness of cardiac resynchronization therapy in patients with atrial fibrillation and heart failure versus patients with sinus rhythm and heart failure. Heart Rate and Cardiac Rhythm Relationships With Bisoprolol Benefit in Chronic Heart Failure in CIBIS II Trial Impact of cardiac resynchronization therapy on exercise performance, functional capacity, and quality of life in systolic heart failure with QRS prolongation: COMPANION trial sub-study. Atrial fibrillation in patients with heart failure: Role of catheter ablation therapies. Long‐term mortality with cardiac resynchronization therapy in the Cardiac Resynchronization‐Heart Failure (CARE‐HF) trial Activity monitoring in heart failure patients with cardiac resynchronization therapy. Cardiac resynchronization therapy improves renal function in human heart failure with reduced glomerular filtration rate. Maintenance of sinus rhythm and survival in patients with heart failure and atrial fibrillation. Randomized trial of cardiac resynchronization in mildly symptomatic heart failure patients and in asymptomatic patients with left ventricular dysfunction and previous heart failure symptoms. Four-year efficacy of cardiac resynchronization therapy on exercise tolerance and disease progression: the importance of performing atrioventricular junction ablation in patients with atrial fibrillation. Predicting the long-term effects of cardiac resynchronization therapy on mortality from baseline variables and the early response a report from the CARE-HF (Cardiac Resynchronization in Heart Failure) Trial. A randomised, controlled study of rate versus rhythm control in patients with chronic atrial fibrillation and heart failure: (CAFÉ-II Study) INvestigation on Routine Follow-up in CONgestive HearT FAilure Patients with Remotely Monitored Implanted Cardioverter Defibrillators SysTems (InContact) Cardiac Resynchronization Therapy and Bone Marrow Cell Transplantation in Patients with Ischemic Heart Failure and Electromechanical Dyssynchrony: A Randomized Pilot Study
Objective : To compare the effects of cardiac resynchronisation therapy ( CRT ) in patients with heart failure ( HF ) in either atrial fibrillation ( AF ) or sinus rhythm ( SR ) . Design : Prospect i ve observational study . Patients : 295 consecutive patients with HF ( permanent AF in 66 , paroxysmal AF in 20 , SR in 209 ; New York Heart Association ( NYHA ) class III or IV ; left ventricular ejection fraction ( LVEF ) ⩽35 % , QRS ⩾120 ms ) . Interventions : All patients underwent CRT without atrioventricular junction ablation . Main outcome measures : The primary end point was the composite of cardiovascular death or unplanned hospitalisation for major cardiovascular events . Secondary end points included the composite of cardiovascular death or hospitalisation for worsening HF . Cardiovascular mortality , total mortality and changes in NYHA class , 6-minute walking distance , quality of life ( Minnesota Living with Heart Failure question naire ) and echocardiographic variables were also considered . Results : Over a follow-up period of up to 6.8 years , no differences emerged between patients in AF or SR in any of the mortality or morbidity end points . The AF and SR groups derived similar improvements in mean NYHA class ( −1.3 vs –1.2 ) , 6-minute walking distance ( 92.3 vs 78.4 m ) and quality of life scores ( −25.2 vs –18.7 ) ( all p<0.001 ) . In both the AF and the SR groups , reductions were seen in left ventricular end-systolic ( −25.9 vs –34.5 ml , both p<0.001 ) and end-diastolic ( −20.2 ml , p = 0.001 vs 26.2 ml , p<0.001 ) volumes and improvements in LVEF ( 4.69 % vs 7.86 % , both p<0.001 ) . Conclusions : Cardiac resynchronisation therapy leads to similar prognostic and symptomatic benefits in patients in AF and SR , even without atrioventricular junction ablation . Echocardiographic improvements are also comparable INTRODUCTION Atrial fibrillation ( AF ) is the most common arrhythmia in patients with heart failure ( HF ) and represents an important comorbidity in these patients . Cardiac resynchronization therapy ( CRT ) has been shown to be beneficial in patients with HF . Whether patients with AF benefit similarly from CRT as their counterparts in sinus rhythm is controversial . METHODS AND RESULTS We conducted a cohort analysis of 175 patients ( 138 men ; age range 57 - 79 years ) who underwent CRT implantation during 2004 - 2008 in our institution . AF was documented in 66 patients ( 37.7 % of patients , 52 men ) . There were no differences in 1- or 2-year mortality between patients with and without AF ( 13.6 % vs 11.79 % , P = 0.7 ; 25.8 % vs 16.9 % , P = 0.2 , respectively ) . There were no differences between the groups in the rate of complications after CRT implantation or in the rate of appropriate electrical shocks . In the subgroup of AF patients with cardiac resynchronization therapy defibrillator ( CRT-D ) ( n = 32 , 48.5 % ) , the 1-year mortality was 3.1 % as compared to 23.5 % in AF patients with cardiac resynchronization therapy pacemaker ( P = 0.03 ) . This difference was no longer evident after 2 years ( 25.0 % vs 26.5 % , P = 0.8 , respectively ) . Ten patients ( 15.2 % ) with AF underwent atrioventricular ( AV ) node ablation . The 2-year mortality of these patients was 10.0 % as compared to 28.6 % in AF patients who did not undergo AV-node ablation ( P = 0.4 ) . CONCLUSIONS In this study , no difference in mortality appears to exist between patients with or without AF and who undergo CRT implantation . Our findings of the beneficial effects of AV-node ablation and CRT-D in AF patients deserve further investigation BACKGROUND Controlled clinical trial data are lacking for cardiac resynchronization therapy ( CRT ) outcomes in patients with advanced heart failure ( HF ) from reduced left ventricular ejection fraction ( HFrEF ) and intermittent atrial fibrillation or flutter ( IAF/AFL ) . OBJECTIVE The purpose of this study was to describe CRT outcomes in patients with IAF/AFL and advanced HF . METHODS HF outcomes in patients in the COMPANION ( Comparison of Medical Therapy , Pacing , and Defibrillation in Heart Failure ) trial with New York Heart Association class III or IV HFrEF , left ventricular ejection fraction ≤0.35 , sinus rhythm at r and omization , and no history of baseline arrhythmia were compared with those with a history of IAF/AFL . RESULTS In those with no history of baseline arrhythmia ( n = 887 ) , compared with optimal pharmacological therapy ( OPT ) with no CRT , the CRT + OPT arms exhibited a significant reduction in the end points of death or any hospitalization ( hazard ratio [ HR ] 0.73 [ 95 % Confidence Interval ( CI ) : 0.60 to 0.89 ] ; P = .002 ) and death or HF hospitalization ( HR 0.53 [ 95 % CI : 0.41 to 0.68 ] ; P < .001 ) . In contrast , in the IAF/AFL subgroup ( n = 293 ) , CRT did not result in improved outcomes compared with OPT ( death or any hospitalization : HR 1.16 [ 95 % CI : 0.83 to 1.63 ] ; P = .38 ; death or HF hospitalization : HR 0.97 [ 95 % CI : 0.64 to 1.46 ] ; P = .88 ) . The interaction between history of AF/AFL and CRT was statistically significant for both outcomes ( P < .05 ) . CONCLUSION In the COMPANION trial , patients with moderate to severe HFrEF and a history of IAF/AFL had no benefit from CRT AIMS In CARE-HF , cardiac resynchronization therapy ( CRT ) lowered morbidity and mortality in patients with moderate to severe heart failure . We examined whether baseline and follow-up electrocardiographic characteristics might predict long-term outcome . METHODS AND RESULTS CARE-HF r and omly assigned 409 patients to medical therapy ( MT ) plus CRT , and 404 patients to MT alone .  Electrocardiographic measurements were made at baseline during sinus rhythm , and at 3 months during paced or spontaneous rhythm depending on treatment assignment . Favourable outcome was defined as freedom from death , urgent transplantation , or cardiovascular hospitalization . Among patients assigned to CRT , 39 % had unfavourable outcomes including 55 deaths . By single variable analysis , ( i ) prolonged PR interval , left QRS axis ( but not QRS duration ) , and left bundle branch block ( BBB ) at baseline , and ( ii ) heart rate , PR , and QRS duration at 3 months predicted unfavourable outcome . By multiple variable analysis , treatment assignment ( P = 0.0001 ) , PR ( P = 0.0004 ) , and right BBB ( P < 0.00013 ) at baseline predicted outcome , whereas baseline JTc and QRS duration at 3 months predicted all-cause mortality and heart failure hospitalization ( P = 0.0071 ) . CONCLUSION In CARE-HF , QRS duration at baseline did not predict outcome , but QRS at 3 months was a predictor by single variable analysis . Patients with prolonged PR interval and the 5 % of patients with right BBB had a particularly high event rate BACKGROUND Cardiac resynchronization therapy ( CRT ) improves quality of life ( QoL ) when measured 3 to 6 months after implantation , but whether these effects are sustained is unknown . The CArdiac Resynchronisation-Heart Failure study is the only long-term r and omized trial of CRT with repeated measures of QoL. METHODS Quality of life was measured at baseline and 3 months using generic European  Quality of Life-5  Dimensions and disease-specific ( Minnesota Living with Heart Failure ) question naires and at 18 months and study -end using the latter instrument . Median follow-up was 29.6 ( interquartile range 23.6 - 34.6 ) months . RESULTS At baseline , patients had a substantially impaired QoL ( mean European Quality of Life-5 Dimensions score 0.60 , 95 % confidence interval [ CI ] 0.58 - 0.62 ) compared to an age-matched general population ( 0.78 , 95 % CI 0.76 - 0.80 ) . Quality of life improved to a greater extent in patients assigned to CRT at each time point ( P < .0001 ) . By 18 months , the mean difference in disease-specific QoL score was 10.7 ( 95 % CI 7.6 - 13.8 ) in favor of CRT , mostly due to improved physical functioning . Differences were sustained thereafter . Quality -adjusted life-years at 18 months increased by 0.13 ( 95 % CI 0.07 - 0.182 ) and by 0.23 ( 95 % CI 0.13 - 0.33 ) at study -end ( both P < .0001 ) . Little heterogeneity of effect across subgroups was observed . CONCLUSION Cardiac resynchronization therapy improves long-term QoL and survival in patients with moderate to severe heart failure . The effects appear sustained , and therefore , the gain in quality -adjusted life years with CRT should be even greater during longer term follow-up Objectives To evaluate the clinical response to cardiac resynchronisation therapy ( CRT ) in patients with heart failure and a normal QRS duration ( < 120 ms ) . Setting Single centre . Patients 60 patients with heart failure and a normal QRS duration receiving optimal pharmacological treatment ( OPT ) . Interventions Patients were r and omly assigned to CRT ( n=29 ) or to a control group ( OPT , n=31 ) . Cardiovascular magnetic resonance was used in order to avoid scar at the site of left ventricular ( LV ) lead deployment . Main outcome measures The primary end point was a change in 6 min walking distance ( 6-MWD ) . Other measures included a change in quality of life scores ( Minnesota Living with Heart Failure question naire ) and New York Heart Association class . Results In 93 % of implantations , the LV lead was deployed over non-scarred myocardium . At 6 months , the 6-MWD increased with CRT compared with OPT ( p<0.0001 ) , with more patients reaching a ≥25 % increase ( 51.7 % vs 12.9 % , p=0.0019 ) . Compared with OPT , CRT led to an improvement in quality -of-life scores ( p=0.0265 ) and a reduction in NYHA class ( p<0.0001 ) . The composite clinical score ( survival for 6 months free of heart failure hospitalisations plus improvement by one or more NYHA class or by ≥25 % in 6-MWD ) was better in CRT than in OPT ( 83 % vs 23 % , respectively ; p<0.0001 ) . Although no differences in total or cardiovascular mortality emerged between OPT and CRT , patients receiving OPT had a higher risk of death from pump failure than patients assigned to CRT ( HR=8.41 , p=0.0447 ) after a median follow-up of 677.5 days . Conclusions CRT leads to an improvement in symptoms , exercise capacity and quality of life in patients with heart failure and a normal QRS duration . ( Clinical Trials.gov number , NCT00480051 . Background — Atrial fibrillation/flutter ( AF ) and heart failure often coexist ; however , the effect of cardiac resynchronization therapy ( CRT ) on the incidence of AF and on the outcome of patients with new-onset AF remains undefined . Methods and Results — In the CArdiac REsynchronisation in Heart Failure ( CARE-HF ) trial , 813 patients with moderate or severe heart failure were r and omly assigned to pharmacological therapy alone or with the addition of CRT . The incidence of AF was assessed by adverse event reporting and by ECGs during follow-up , and the impact of new-onset AF on the outcome and efficacy of CRT was evaluated . By the end of the study ( mean duration of follow-up 29.4 months ) , AF had been documented in 66 patients in the CRT group compared with 58 who received medical therapy only ( 16.1 % versus 14.4 % ; hazard ratio 1.05 ; 95 % confidence interval , 0.73 to 1.50 ; P=0.79 ) . There was no difference in the time until first onset of AF between groups . Mortality was higher in patients who developed AF , but AF was not a predictor in the multivariable model ( hazard ratio 1.17 ; 95 % confidence interval , 0.82 to 1.67 ; P=0.37 ) . In patients with new-onset AF , CRT significantly reduced the risk for all-cause mortality and all other predefined end points and improved ejection fraction and symptoms ( no interaction between AF and CRT ; all P>0.2 ) . Conclusions — Although CRT did not reduce the incidence of AF , CRT improved the outcome regardless of whether AF developed BACKGROUND Cardiac resynchronisation is a promising new intervention for patients with heart failure , left ventricular systolic dysfunction and ventricular dyssynchrony . OBJECTIVE The CARE-HF trial is design ed to evaluate the long-term effects of cardiac ( atrio-bi-ventricular ) resynchronisation on the mortality and morbidity of patients with heart failure due to left ventricular systolic dysfunction already receiving diuretics and optimal medical therapy with ACE inhibitors and beta-blockers ( where indicated and tolerated ) . METHODS AND RESULTS Approximately 800 patients will be r and omised to device therapy or control and followed for a minimum of 18 months . A pragmatic study design has been chosen that does not attempt to conceal allocation from investigators or patients because it is impossible to guarantee maintenance of blinding for the duration of the study . The end-points committee will adjudicate events in a blinded fashion . Since cardiac resynchronisation may alter other aspects of the management of the patient , as would occur in clinical practice , the study should be considered a comparison of strategies rather than simply of a device . The primary end-point is all-cause mortality or unplanned cardiovascular hospitalisation . The study should complete recruitment during 2002 and report in 2004 AIM Telemonitoring ( TM ) is a safe and efficient monitoring system for internal cardioverter defibrillator device ( ICD ) recipients . TM has been used to track info on the clinical status of heart failure patients treated by ICD and /or cardiac resynchronisation therapy defibrillator ( CRT-D ) .  The aim of this study was to investigate the impact of TM on clinical outcomes in a population of CRT-D patients with heart failure . METHODS In a multicentre , r and omised study , patients with chronic heart failure , New York Heart Association ( NYHA ) functional class II or III , left bundle branch block , severe left ventricle ejection fraction reduction ( LVEF < 35 % ) have been identified and screened . RESULTS One hundred and ninety-one patients have been r and omised to receive either a CRT-D with TM or a CRT-D with traditional ambulatory monitoring ( control group ) and completed the 12-month study follow-up . Primary endpoints were all cause death , cardiac death and hospital admission for heart failure . Secondary endpoints were atrial fibrillation , sustained episodes , non-sustained and self terminated ventricular tachyarrhythmia , sustained ventricular tachycardia , and ventricular fibrillation , ICD shocks and percentage of CRT-D responder patients . Univariate analysis identified the following factors predicting hospitalisation : TM , age , chronic kidney disease , hypercholesterolaemia , LVEF and NYHA class . At multivariate analysis , TM was the only factor predicting heart failure hospitalisation ( hazard ratio 0.6 , 0.42 - 0.79 , 95 % CI , p = 0.002 ) , without affecting overall mortality and cardiac deaths events . CONCLUSIONS Taken together , our data indicate the importance of TM in predicting heart failure hospitalisation in patients treated with The prevalence of atrial fibrillation ( AF ) in patients with heart failure is high , but data about the effects of cardiac resynchronization therapy ( CRT ) in patients with chronic AF are scarce . In this prospect i ve observational study of 263 consecutive patients , CRT was performed in 96 patients ( 37 % ) with chronic AF and 167 patients ( 63 % ) with sinus rhythm ( SR ) .  Echocardiographic and clinical parameters were evaluated at baseline and 3 and 12 months . Reverse left ventricular ( LV ) remodeling is defined as LV end-systolic volume decrease > or = 10 % . Hospitalization rates for heart failure in the year before and after implantation were compared . Baseline characteristics between patients with and without AF were similar , but the AF group had smaller LV end-systolic and end-diastolic volumes and larger left atrial dimensions . New York Heart Association class , 6-minute walking distance , quality -of-life score , LV ejection fraction , and mitral regurgitation improved significantly at 3 and 12 months in both groups , and the changes were similar . Reverse LV remodeling after 3 and 12 months was 74 % and 82 % ( AF group ) versus 77 % and 83 % , respectively ( SR group , p = 0.79 ) . After 1 year , cardioversion had occurred in 25 % of patients with AF . In the year after implantation , significant decreases in hospitalizations for heart failure in both groups ( 84 % and 90 % ) were documented . Long-term mortality was almost equal in both groups . In conclusion , this large-scale study shows that the benefit of CRT in patients with chronic AF and heart failure is similar to that in patients with SR . Patients with chronic AF and heart failure should be considered c and i date s for CRT Background —&bgr;-Blockade – induced benefit in heart failure ( HF ) could be related to baseline heart rate and treatment-induced heart rate reduction , but no such relationships have been demonstrated . Methods and Results —In CIBIS II , we studied the relationships between baseline heart rate ( BHR ) , heart rate changes at 2 months ( HRC ) ,  nature of cardiac rhythm ( sinus rhythm or atrial fibrillation )  , and outcomes ( mortality and hospitalization for HF ) . Multivariate analysis of CIBIS II showed that in addition to & bgr;-blocker treatment , BHR and HRC were both significantly related to survival and hospitalization for worsening HF , the lowest BHR and the greatest HRC being associated with best survival and reduction of hospital admissions . No interaction between the 3 variables was observed , meaning that on one h and , HRC-related improvement in survival was similar at all levels of BHR , and on the other h and , bisoprolol-induced benefit over placebo for survival was observed to a similar extent at any level of both BHR and HRC . Bisoprolol  reduced mortality in patients with sinus rhythm ( relative risk 0.58 , P < 0.001 ) but not in patients with atrial fibrillation ( relative risk 1.16 , P = NS ) . A similar result was observed for cardiovascular mortality and hospitalization for HF worsening . Conclusions —BHR and HRC are significantly related to prognosis in heart failure . & bgr;-Blockade with bisoprolol further improves survival at any level of BHR and HRC and to a similar extent . The benefit of bisoprolol is question able , however , in patients with atrial fibrillation BACKGROUND A total of 405 participants in the Comparison of Medical Therapy , Pacing , and Defibrillation in Heart Failure trial were prospect ively enrolled in an exercise sub- study design ed to study the influence of cardiac resynchronization therapy ( CRT ) on measures of exercise capacity , functional capacity , and quality of life ( QOL ) . METHODS AND RESULTS Sub study eligibility included New York Heart Association ( NYHA ) functional Class III or IV heart failure , left ventricular ejection fraction < or = 0.35 , QRS interval of > or = 120 ms , normal sinus rhythm , a heart failure hospitalization ( or equivalent ) within 1 year , a peak VO2 < or = 22 mL x kg x min , the ability to walk 150 to 425 meters in 6 minutes , forced expiratory volume in 1 second/forced vital capacity > or = 50 % , and no clinical indication for a pacemaker or implantable cardioverter-defibrillator . Patients were r and omized in a 1:4 ratio to optimal medical therapy ( OPT ) or to OPT plus CRT .  Cardiopulmonary exercise testing ( peak VO2 and 6-minute walk distance [ 6MWD ] ) and assessment of NYHA functional class and QOL were assessed at baseline and at 3 and 6 months of assigned therapy . There was no significant improvement in peak VO2 at 6 months in the CRT group compared with the OPT group ( + 0.63 mL x kg x min ) by unadjusted analysis ( P = .05 ) or by analyses adjusted for missing data . Thus the primary end point of the study was not met . There was significantly greater improvement in the 6MWD in the CRT group compared with the OPT group at both 3 and 6 months by both statistical methods ( P < or = .045 ) . Likewise , a greater proportion of CRT patients improved by 1 or more NYHA functional classes ( P < .01 ) at 3 months and had better QOL scores ( P < .01 ) at 3 and 6 months compared with the OPT patients . Baseline peak VO2 predicted clinical events ( time to death , time to death or first hospitalization , or time to death and first heart failure hospitalization : P < .05 ) in CRT participants . CONCLUSION CRT patients with moderate to advanced symptoms of systolic heart failure and prolonged QRS intervals benefit from the addition of CRT to OPT in terms of exercise capacity , functional status , and QOL .  CRT should be considered st and ard therapy in this select group of heart failure patients Atrial fibrillation ( AF ) represents the most common sustained cardiac arrhythmia in patients with heart failure ( HF ) . AF in HF patients is associated with worsening of symptoms and also results in a substantial increase in mortality . Although HF patients in sinus rhythm have a better outcome than patients with AF , several r and omized studies investigating pharmacological rhythm control versus rate control have shown no advantage of one strategy over the other in terms of patient outcomes . Catheter-based ablation therapy is a newer therapeutic option with a rapidly evolving and changing role in the management of this arrhythmia . In the present review , the authors discuss the epidemiology , pathophysiology and prognostic significance of AF in patients with HF . Exclusively addressed are studies investigating catheter-based ablation for rhythm-control and rate-control therapies in the management of AF in HF patients The Cardiac Resynchronization‐Heart Failure ( CARE‐HF ) study helped establish an important role for cardiac resynchronization therapy ( CRT ) in the management of selected patients with heart failure . We now report the long‐term outcome during and subsequent to the r and omized trial BACKGROUND Cardiac resynchronization therapy ( CRT ) improves functional capacity in heart failure patients . This study aim ed to prospect ively analyze long-term device-based monitoring of physical activity in patients undergoing CRT .  METHODS AND RESULTS The Activity Log Index ( ALI ) , calculated by CRT devices , represents the percentage of time when acceleration exceeds a threshold and monitors the physical activity . Data from 178 CRT patients ( New York Heart Association III 91 % , left ventricular ejection fraction 21+/-6 % , left ventricular end-diastolic diameter 69+/-9 mm , QRS 159+/-27 ms , sinus rhythm 81 % ) were retrieved . The ALI increased from a baseline value of 3.6+/-2.0 to 11.2+/-4.6 ( p<0.005 ) 104 weeks after initiation of CRT . A plateau was reached at approximately 12 weeks and thereafter ALI remained stable for up to 2 years . The magnitude of the changes in ALI was similar in patients with different etiologies and underlying rhythms . Despite similar values at baseline , elderly patients ( > or=65 years ) exhibited significantly lower ALI values than younger patients during the follow-up and at the plateau ( 9.5+/-4.2 vs 13.3+/-4.8 , p<0.001 ) . CONCLUSIONS Device-based monitoring of physical activity in CRT patients is feasible . CRT result ed in a large and long-term increase in physical activity BACKGROUND Renal dysfunction is an important independent prognostic factor in heart failure ( HF ) .  Cardiac resynchronization therapy ( CRT ) improves functional status and left ventricular ( LV ) function in HF patients with ventricular dyssynchrony , but the impact of CRT on renal function is less defined . We hypothesized that CRT would improve glomerular filtration rate as estimated by the abbreviated Modification of Diet in Renal Disease equation ( eGFR ) . METHODS AND RESULTS The Multicenter InSync R and omized Clinical Evaluation ( MIRACLE ) study evaluated CRT in HF patients with NYHA Class III-IV , ejection fraction < or=35 % , and QRS > or=130 ms . Patients were evaluated before and 6 months after r and omization to control ( n = 225 ) or CRT ( n = 228 ) . Patients were categorized according to their baseline eGFR : > or=90 ( category A ) , 60 < or = eGFR < 90 ( category B ) , and 30 < or = eGFR < 60 ( category C ) mL/min per 1.73 m(2 ) . CRT improved LV function in all categories . Compared with control , CRT increased eGFR ( -2.4 + /- 1.2 vs. + 2.7 + /- 1.2 mL/min per 1.73 m(2 ) ; P = .003 ) and reduced blood urea nitrogen ( + 6.4 + /- 2.4 vs. -1.1 + /- 1.5 mg/mL ; P = .008 ) in category C , whereas no differences were observed in categories A and B. CONCLUSIONS CRT increased eGFR and reduced blood urea nitrogen  in HF patients with moderately reduced baseline eGFR . By improving cardiac function , CRT can indirectly improve renal function , underscoring the importance of cardiorenal interaction and providing another mechanism for the beneficial effects of CRT OBJECTIVES The goal of this study was to evaluate the relationship between the presence of sinus rhythm and outcomes in patients with a history of congestive heart failure ( CHF ) and atrial fibrillation ( AF ) . BACKGROUND The value of sinus rhythm maintenance in patients with AF and heart failure ( HF ) is uncertain . METHODS A total of 1,376 patients with AF , ejection fraction < or = 35 % , and heart failure symptoms were r and omized to a rhythm- or rate-control strategy .  Detailed efficacy analyses were used to evaluate the independent effects of treatment strategy and the presence of sinus rhythm on cardiovascular outcomes . RESULTS Overall , 445 ( 32 % ) patients died and 402 ( 29 % ) experienced worsening HF . The rhythm-control strategy was not predictive of cardiovascular mortality ( hazard ratio [ HR ] : 0.90 , 95 % confidence interval [ CI ] : 0.70 to 1.16 ; p = 0.41 ) , all-cause death ( HR : 0.86 , 95 % CI : 0.69 to 1.08 ; p = 0.19 ) , or worsening HF ( HR : 0.86 , 95 % CI : 0.68 to 1.10 ; p = 0.23 ) . In analyses devised to isolate the effect of underlying rhythm , sinus rhythm was not associated with cardiovascular mortality [ HR : 1.22 , 95 % CI : 0.80 to 1.87 ; p = 0.35 ) , total mortality [ HR : 1.11 , 95 % CI : 0.78 to 1.58 ; p = 0.57 ) , or worsening HF [ HR : 0.62 , 95 % CI : 0.37 to 1.02 ; p = 0.059 ) . CONCLUSIONS A rhythm-control strategy or the presence of sinus rhythm are not associated with better outcomes in patients with AF and CHF OBJECTIVES We sought to determine the effects of cardiac resynchronization therapy ( CRT ) in New York Heart Association ( NYHA ) functional class II heart failure ( HF ) and NYHA functional class I ( American College of Cardiology/American Heart Association stage C ) patients with previous HF symptoms . BACKGROUND Cardiac resynchronization therapy improves left ventricular ( LV ) structure and function and clinical outcomes in NYHA functional class III and IV HF with prolonged QRS . METHODS Six hundred ten patients with NYHA functional class I or II heart failure with a QRS > or = 120 ms and a LV ejection fraction < or = 40 % received a CRT device ( + /-defibrillator )  and were r and omly assigned to active CRT ( CRT-ON ; n = 419 ) or control ( CRT-OFF ; n = 191 ) for 12 months . The primary end point was the HF clinical composite response , which scores patients as improved , unchanged , or worsened . The prospect ively powered secondary end point was LV end-systolic volume index . Hospitalization for worsening HF was evaluated in a prospect i ve secondary analysis of health care use . RESULTS The HF clinical composite response end point , which compared only the percent worsened , indicated 16 % worsened in CRT-ON compared with 21 % in CRT-OFF ( p = 0.10 ) . Patients assigned to CRT-ON experienced a greater improvement in LV end-systolic volume index ( -18.4 + /- 29.5 ml/m2 vs. -1.3 + /- 23.4 ml/m2 , p < 0.0001 ) and other measures of LV remodeling . Time-to-first HF hospitalization was significantly delayed in CRT-ON ( hazard ratio : 0.47 , p = 0.03 ) . CONCLUSIONS The REVERSE ( REsynchronization reVErses Remodeling in Systolic left vEntricular dysfunction ) trial demonstrates that CRT , in combination with optimal medical therapy ( + /-defibrillator ) , reduces the risk for heart failure hospitalization and improves ventricular structure and function in NYHA functional class II and NYHA functional class I ( American College of Cardiology/American Heart Association stage C ) patients with previous HF symptoms . ( REsynchronization reVErses Remodeling in Systolic Left vEntricular Dysfunction [ REVERSE ] ; NCT00271154 ) OBJECTIVES The goal of this study was to investigate the effects of cardiac resynchronization therapy ( CRT ) in heart failure patients with permanent atrial fibrillation ( AF ) and the role of atrioventricular junction ( AVJ ) ablation . BACKGROUND Cardiac resynchronization therapy has been proven effective in heart failure patients with sinus rhythm ( SR ) . However , little is known about the effects of CRT in heart failure patients with permanent AF . METHODS Efficacy of CRT on ventricular function , exercise performance , and reversal of maladaptive remodeling process was prospect ively compared in 48 patients with permanent AF in whom ventricular rate was controlled by drugs , thus result ing in apparently adequate delivery of biventricular pacing ( > 85 % of pacing time ) , and in 114 permanent AF patients , who had undergone AVJ ablation ( 100 % of resynchronization therapy delivery ) . The clinical and echocardiographic long-term outcomes of both groups were compared with those of 511 SR patients treated with CRT . RESULTS Both SR and AF groups showed significant and sustained improvements of all assessed parameters ( model p < 0.001 for all parameters ) . However , within the AF group , only patients who underwent ablation showed a significant increase of ejection fraction ( p < 0.001 ) , reverse remodeling effect ( p < 0.001 ) , and improved exercise tolerance ( p < 0.001 ) ; no improvements were observed in AF patients who did not undergo ablation . CONCLUSIONS Heart failure patients with ventricular conduction disturbance and permanent AF treated with CRT showed large and sustained long-term ( up to 4 year ) improvements of left ventricular function and functional capacity , similar to patients in SR , only if AVJ ablation was performed OBJECTIVES This study was design ed to investigate whether selected baseline variables and early response markers predict the effects of cardiac resynchronization therapy ( CRT ) on long-term mortality . BACKGROUND Cardiac resynchronization therapy reduces long-term morbidity and mortality in patients with moderate or severe heart failure and markers of cardiac dyssynchrony , but not all patients respond to a similar extent . METHODS In the CARE-HF ( Cardiac Resynchronization in Heart Failure ) study , 813 patients with heart failure and markers of cardiac dyssynchrony were r and omly assigned to receive or not receive CRT in addition  to  pharmacological treatment  and were followed for a median of 37.6 months . A model including assigned treatment , 15 pre-specified baseline variables , and 8 markers of response at 3 months was constructed to predict all-cause mortality . RESULTS On multivariable analysis , plasma concentration of amino terminal pro-brain natriuretic peptide ( univariate and multivariable model chi-square test : 105.0 and 48.4 ; both p < 0.0001 ) and severity of mitral regurgitation ( chi-square test : 44.0 and 17.9 ; both p < 0.0001 ) at 3 months , regardless of assigned treatment , were the strongest predictors of mortality . Ischemic heart disease as the cause of ventricular dysfunction ( chi-square test : 34.9 and 7.4 ; p < 0.0001 and p = 0.0066 ) , being in New York Heart Association functional class IV ( chi-square test : 18.8 and 9.6 ; p < 0.0001 and p = 0.0020 ) , or having less interventricular mechanical delay ( chi-square test : 29.8 and 8.8 ; p < 0.0001 and p = 0.0029 ) at baseline all predicted a worse outcome . However , the reduction in mortality in patients assigned to CRT was similar before ( hazard ratio : 0.602 ; 95 % confidence interval : 0.468 to 0.774 ) and after ( hazard ratio : 0.679 ; 95 % confidence interval : 0.494 to 0.914 ) adjustment for variables measured at baseline and at 3 months . CONCLUSIONS Patients who have more severe mitral regurgitation or persistently elevated amino terminal pro-brain natriuretic peptide  despite treatment for heart failure , including CRT , have a higher mortality . However , patients assigned to CRT had a lower mortality even after adjusting for variables measured before and 3 months after intervention . The effect of CRT on mortality can not be usefully predicted using such information . ( CARE-HF CArdiac Resynchronization in Heart Failure ; NCT00170300 ) Background : Atrial fibrillation ( AF ) and heart failure ( HF ) often coexist . The aim was to investigate whether restoring sinus rhythm ( SR ) could improve cardiac function , symptoms , exercise capacity and quality of life ( QoL ) in patients with chronic heart failure . Methods : Patients with HF and persistent AF receiving guideline -recommended treatments , including anticoagulants , were eligible for the study . Patients were r and omised to either rhythm ( treated with amiodarone for at least 3 months prior to attempting biphasic external cardioversion and continued amiodarone long-term if SR was restored ) or rate control . Anticoagulants were continued throughout the study regardless of rhythm , unless contraindications developed . Both groups were treated with beta blockers and /or digoxin to reduce the heart rate to < 80 bpm at rest and < 110 bpm after walking . Symptoms , walk distance ( 6-minute corridor walk test , 6MWT ) , QoL and cardiac function were assessed at baseline and 1 year . Results : 61 patients with HF and persistent AF ( median duration 14 months ( IQR 5 to 32 ) ) were r and omly assigned to a rate or rhythm control strategy . Of patients assigned to rhythm control ( n = 30 ) , 66 % were in SR at 1 year , and 90 % of those assigned to rate control ( n = 31 ) achieved the heart rate target . At 1 year , NYHA class ( p = 0.424 ) and 6MWT distance ( p = 0.342 ) were similar between groups but patients assigned to rhythm control had improved LV function ( p = 0.014 ) , NT-proBNP concentration ( p = 0.046 ) and QoL ( p = 0.019 ) compared with those assigned to rate control . Greatest improvement was seen in patients in whom SR was maintained . Conclusion : Restoring SR in patients with AF and heart failure may improve QoL and LV function when compared with a strategy of rate control Background In heart failure ( HF ) patients with implantable cardioverter defibrillators ( ICD ) or cardiac resynchronisation therapy defibrillators ( CRT-D )  , remote monitoring has been shown to result in at least non-inferior outcomes relative to in-clinic visits . We aim ed to provide further evidence for this effect , and to assess whether adding telephone follow-ups to remote follow-ups influenced outcomes . Methods InContact was a prospect i ve , r and omised , multicentre study . Subjects receiving quarterly automated follow-up only ( telemetry group )  were compared to those receiving personal physician contact .  Personal contact patients were further divided into those receiving automated follow-up plus a telephone call ( remote+phone subgroup ) or in-clinic visits only . Results Two hundred and ten patients underwent r and omisation ( telemetry n = 102 ; personal contact n = 108 [ remote+phone : n = 53 ; visit : n = 55 ] ) . Baseline characteristics were comparable between groups and subgroups . Over 12 months , 34.8 % of patients experienced deterioration of their Packer Clinical Composite Response , with no significant difference between the telemetry group and personal care ( p > 0.999 ) , remote+phone ( p = 0.937 ) or visit ( p = 0.940 ) patients ; predefined non-inferiority criteria were met . Mortality rates ( 5.2 % overall ) were comparable between groups and subgroups ( p = 0.832/p = 0.645 ) , as were HF-hospitalisation rates ( 11.0 % overall ; p = 0.605/p = 0.851 ) . The proportion of patients requiring ≥1 unscheduled follow-up was nominally higher in telemetry and remote+phone groups ( 42.2 and 45.3 % ) compared to the visit group ( 29.1 % ) . Overall , ≥ 1 ICD therapy was delivered to 15.2 % of patients . Conclusion In HF patients with ICDs/CRT-Ds , quarterly remote follow-up only over 12 months was non-inferior to regular personal contact . Addition of quarterly telephone follow-ups to remote monitoring does not appear to offer any clinical advantage . Trial registration clinical trials.gov : NCT01200381 ( retrospectively registered on September 13th 2010 ) Most studies have confirmed the beneficial effects of autologous bone marrow mononuclear cell ( BMMC ) transplantation on angina , myocardial perfusion , regional wall motion , and LV ejection fraction ( LVEF ) .  Cardiac resynchronization therapy ( CRT ) has also shown a beneficial effect in patients with heart failure ( HF ) and electrical/mechanical dyssynchrony . However , the relative contribution of BMMC and CRT in patients with ischemic HF and electromechanical dyssynchrony has never been investigated . The aim of this study was to evaluate the benefit of combining BMMC transplantation with CRT in patients with severe ischemic HF , left bundle branch block ( LBBB ) , and mechanical dyssynchrony . Patients with ischemic HF , LVEF < 35 % , LBBB , and mechanical dyssynchrony underwent intramyocardial transplantation of BMMC and CRTD system implantation . This r and omized , single-blind , crossover study compared clinical and echocardiographic parameters during two follow-up periods : 6 months of active CRT ( BMMC + CRTact ) and 6 months of inactive CRT ( BMMC + CRTinact ) . Physical performance was assessed by means of a 6-min walking test . Myocardial perfusion was evaluated by SPECT . Quality of Life ( QoL ) was assessed through the Minnesota Living with HF Question naire ( MLwHFQ ) . Twenty-six patients ( 64 ± 7 years ) were enrolled in the study .  The distance covered by the patients during the 6-min walking test significantly increased in the BMMC + CRTinact phase ( BMMC therapy only ) in comparison with the baseline ( 269 ± 68 vs 206 ± 51 ; p = 0.007 ) and in the BMMC + CRTact phase ( BMMC therapy + CRT ) in comparison with the BMMC + CRTinact ( 378 ± 59 vs 269 ± 68 ; p < 0.001 ) . The summed rest and stress score ( SPECT ) decreased significantly in the BMMC + CRTact and BMMC + CRTinact phases in comparison with the baseline ( p ≤ 0.03 ) . Both phases showed equivalent myocardial perfusion in the segments into which BMMC had been injected . QoL score was significantly lower in the BMMC + CRTinact phase than at the baseline ( 44.1 ± 14 vs 64.8 ± 19 ; p < 0.001 ) , and in the BMMC + CRTact phase than in the BMMC + CRTinact phase ( 26.4 ± 12 vs 44.1 ± 14 ; p = 0.004 ) . BMMC and CRT seem to act independently on myocardial perfusion and electromechanical dyssynchrony , respectively . Combining these two complementary therapies can significantly improve LV performance in patients with severe HF and electromechanical dyssynchrony
Conclusion The results of our meta- analysis suggest that AF was associated with decreased CRT benefits in patients with HF .
CRT , however , benefits patients with AF with AVJ ablation
Background Cardiac resynchronisation therapy ( CRT ) is beneficial in selected patients with heart failure ( HF ) in normal sinus rhythm ( NSR ) .