Mp-453086-7 atrioventricular junction ablation and cardiac resynchronization therapy in patients with nonobstructive hypertrophic cardiomyopathy and permanent atrial fibrillation

Atrial fibrillation (AF) is the most common arrhythmia encountered with hypertrophic cardiomyopathy (HCM) and is associated with adverse cardiovascular outcomes. The outcomes of ablate-and-pace strategy for the management of refractory AF in HCM patients are unclear. The objective of this retrospective study was to investigate the incremental benefit and safety of atrioventricular junction (AVJ) ablation and biventricular pacing (CRT) in patients with nonobstructive (NO) HCM and symptomatic permanent AF. Between January 2016 and December 2021, 20 patients with NO-HCM underwent AVJ ablation + CRT for uncontrolled permanent AF. The control group included 86 NO-HCM patients with permanent AF treated by the best medical rate-control therapy. A 1:1 propensity score (PS) matching analysis weighted on clinical (age, gender, hypertension, diabetes, recent hospitalization for heart failure [HF], cerebrovascular accident, chronic kidney disease, NYHA class) and imaging characteristics (left ventricle [LV] ejection fraction [EF], left atrial dimension, estimated pulmonary hypertension, maximal wall thickness, late gadolinium enhancement extension) was performed to compare outcomes between groups. The primary endpoint was a composite of all-cause mortality and hospitalization due to HF during follow-up. PS matching yielded 40 patients, 20 patients with AVN ablation + CRT (Group 1), and 20 patients in best medical rate-control therapy (Group 2). CRT was achieved in all patients (100% CRT-D). No acute procedure-related complications were noted. The mean paced QRS duration was 119±12 ms. Within the matched cohort, mean age was 64±7 years, the median time since AF diagnosis was 2 years (IQR 0.8-2.3 years), the mean LV EF was 53%±5%. During a median follow-up period of 23 months (IQR 19-27 months), patients in Group 1 had a lower risk of primary outcomes (HR 0.7; 95% CI 0.47-0.92; p=0.04), mainly driven by a significantly lower risk of HF hospitalization (HR 0.4; 95% CI 0.23–0.75; p=0.02). Compared to Group 2, Group 1 experienced a significant improvement in LV EF (55%±5% [Group 1] vs 48%±6% [Group 2], p=0.03) and improvement in NYHA class. No long-term device-related complications were noted. Ablation of AVJ + CRT was safe and superior to medical therapy in reducing HF hospitalization in patients with NO-HCM and permanent AF.