Cardiac resynchronization therapy in the setting of permanent atrial fibrillation and heart failure

Heart failure and atrial fibrillation have been called the twin modern epidemics. They are often present concomitantly and are believed to directly predispose to each other. They form a sinister synergy, and management of atrial fibrillation in the setting of heart failure is challenging; relatively new therapeutic strategies like cardiac resynchronization therapy and catheter ablation need to be validated in this complex setting. This review will summarize the current management strategies of atrial fibrillation in the setting of heart failure.

Recent observational studies and a single randomized trial point towards a potential benefit of cardiac resynchronization therapy in heart-failure patients with permanent atrial fibrillation; particularly, biventricular pacing was superior compared with conventional right-ventricular stimulation. However, recent results suggest that even a relatively high-percentage biventricular capture may be inadequate, and that the benefits of cardiac resynchronization therapy may only be extended to chronic atrial fibrillation patients with previous atrioventricular junctional ablation.

Rigorously designed clinical studies are needed to clarify the role of ablation, resynchronization therapy and drugs when atrial fibrillation complicates the course of heart failure.