Clinical trial NCT06833138: Atrioventricular Node Ablation and Conduction System Pacing in Patients with Well Controlled Permanent Atrial Fibrillation (AF), Heart Failure and Preserved Ejection Fraction: Heart Rate Regularization Versus Medical Rate Control
Official title: Atrioventricular (AV) Node Ablation and Conduction System Pacing in Patients with Well Controlled Permanent Atrial Fibrillation (AF), Heart Failure and Preserved Ejection Fraction: Heart Rate Regularization Vs. Medical Rate Control
Study type: INTERVENTIONAL
Overall status: NOT_YET_RECRUITING
Phase: NA
Conditions: Heart Failure with Preserved Ejection Fraction
Atrial Fibrillation, Persistent
Keywords: Heart failure
Cardiac Resynchronization Therapy
Conduction System Pacing
Lead sponsor: French Cardiology Society
Sponsor class: OTHER
Collaborators: name: Medtronic France SAS
name: ClinSearch
First posted: 2025-02-18
Enrollment: 266
Sex: ALL
Minimum age (years): 18
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: PARALLEL
Intervention model description: Randomization 1:1 Intervention arm: Conduction system pacing (pacemaker implantation) + atrioventricular node ablation Control arm: optimal pharmacological therapy
Primary purpose: TREATMENT

Brief summary: The goal of this clinical trial is to assess the clinical efficacy of physiological pacing combined with atrioventricular node ablation, in patients with Heart Failure with preserved Ejection Fraction (HFpEF) and well controlled permanent atrial fibrillation.The main question it aims to answer is that heart rate regularization added to physiological pacing - preventing the deleterious effect of right ventricular apical pacing - would reduce mortality and heart failure hospitalizations.

Researchers will compare physiological pacing combined with atrioventricular node ablation (intervention arm) versus optimal pharmacological therapy (control arm) to see if physiological pacing combined with atrioventricular node ablation reduce time to the composite of all-cause mortality or hospitalization due to heart failure or intravenous diuretics (time frame 24 months).

Participants will :

* Be randomized in intervention arm or control arm.
* Visit the clinic 3 months, 12 months and 24 months after the randomization for checkups and tests.

Detailed description: Heart failure with preserved ejection fraction is a major public health issue affecting 4.9% of general population aged ≥ 60 years. It accounts for more than half of all heart failure hospital admissions. Atrial fibrillation is very common in this diseased population as pathophysiologies are highly interrelated. Atrial fibrillation occurs in two thirds of Heart failure with preserved ejection patients at some point in the natural history and confers a poor prognosis. Therapeutic alternatives are currently limited as patients with permanent Atrial fibrillation and Heart failure with preserved ejection are often treated with drug therapies for lenient rate control.

Recently, the APAF-CRT mortality trial demonstrated a reduction in mortality and hospitalization in Heart Failure and Atrial fibrillation patients treated with Atrioventricular node ablation plus Cardiac Resynchronization Therapy versus pharmacological rate control, irrespective of their baseline Ejection Fraction. The optimal rate regularization achieved with atrioventricular node ablation emerges as the main determinant of reduction in mortality and hospitalization. This conclusion is supported by old robust physiology studies showing that beat-to-beat heart rate irregularity has significant hemodynamic effects and notably decreases cardiac output. However, no specific trials have been conducted in patients with Heart failure with preserved ejection, a population for whom treatment strategies that effectively improve outcomes are sparse. We aim at analyzing the benefit of heart rate regularization and physiological pacing in patients with Heart failure with preserved ejection (Left Ventricular Ejection Fraction ≥ 50%) and permanent Atrial Fibrilation.

We hypothesize that heart rate regularization added to physiological pacing - preventing the deleterious effect of right ventricular apical pacing - would reduce mortality and Heart Failure hospitalizations.

Eligibility criteria: Inclusion Criteria:

* Permanent atrial fibrilation \> 6 months
* Preserved Left Ventricular Ejection Fraction ≥ 50%
* ≥ 1 heart failure hospitalization in the previous year
* NYHA (New York Heart Association) score ≥ 2
* Presence of at least one of the following criteria related to diastolic dysfunction:

  * E/e' ratio \> 9
  * Left Ventricular mass \> 95 g/m2 (female) or \> 115 g/m2 (male) with h/R ratio \> 0.42
  * NT pro BNP (B-type Natriuretic Peptide) \> 365 pg/mL or BNP (B-type Natriuretic Peptide) \> 105 pg/mL
* Narrow QRS ≤ 120 ms
* Average heart rate ≤ 110/min on 24 hours Holter monitoring
* Age over 18-year-old
* Capacity to understand the nature of the study, legal ability and willingness to give informed consent
* Patient covered by a social insurance
* Effective contraception and a negative pregnancy test in women of a childbearing age

Exclusion Criteria:

* Patient eligible for atrial fibrilation catheter ablation
* Life expectancy \< 12 months
* Severe chronic kidney disease (estimated Glomerular Filtration Rate ≤ 20 ml/1,73 m2)
* Severe respiratory disease (severe chronic obstructive pulmonary disease with Gold ≥ 3 and/or chronic oxygen therapy)
* Class III obesity (Body Mass Index ≥ 40)
* Confirmed or suspected infiltrative cardiomyopathy (amyloidosis, sarcoidosis, Fabry disease, others)
* Obstructive hypertrophic cardiomyopathy
* Previous implanted devices (Pacemaker / Implantable Cardioverter-Defibrillator / Cardiac Resynchronization Therapy)
* Other indication for pacemaker implantation
* Indication for implantable cardioverter-defibrillator
* Ambulatory ≤ 50% of time
* Pregnant women
* Breast-feeding women

Primary outcomes:
measure: Time to the composite of all-cause mortality or hospitalization due to heart failure or intravenous diuretics.
timeFrame: 24 months
Secondary outcomes:
measure: Time to all-cause mortality
timeFrame: 24 months
measure: Time to Cardiovascular mortality
timeFrame: 24 months
measure: Time to heart failure hospitalization
timeFrame: 24 months
measure: Change in New York Heart Association score
timeFrame: 24 months
measure: Change in B-type natriuretic peptide level
timeFrame: 24 months
measure: Major adverse events following pacemaker implantation
timeFrame: 24 months
measure: Major adverse events following atrioventricular node ablation
timeFrame: 24 months
Other outcomes:
Locations:
city: Aalst
country: Belgium
facility: OLV Aalst
city: Leuven
country: Belgium
facility: UZ Leuven
city: Ottignies-Louvain-la-Neuve
country: Belgium
facility: Clinique St Pierre Ottignies
city: Brest
country: France
facility: CHRU de Brest - Hôpital de la Cavale Blanche
city: Caen
country: France
facility: CHRU de Caen
city: Chambray-lès-Tours
country: France
facility: CHRU de Tours - Trousseau
city: Grenoble
country: France
facility: CHU Grenoble Alpes
city: La Rochelle
country: France
facility: Groupe Hospitalier La Rochelle-Ré-Aunis
city: Lille
country: France
facility: CHRU Lille
city: Lomme
country: France
facility: GHICL Allome - Hôpital St Philibert
city: Montpellier
country: France
facility: Clinique Millenaire
city: Nantes
country: France
facility: CHU de Nantes - Hôpital Nord Laennec
city: Pessac
country: France
facility: CHU de Bordeaux - Hôpital Cardiologique du Haut-Lévèque
city: Poitiers
country: France
facility: CHU Poitiers
city: Rouen
country: France
facility: CHU de Rouen
Study officials:
affiliation: CHU de Rouen, France
name: Frédéric ANSELME, MD
role: PRINCIPAL_INVESTIGATOR
affiliation: CHU de Rouen, France
name: Corentin CHAUMONT, MD
role: STUDY_DIRECTOR
References: