Effect of cardiac resynchronization therapy on conversion of persistent atrial fibrillation to sinus rhythm

Background  Spontaneous conversion of persistent atrial fibrillation to sinus rhythm (SR) has anecdotally been reported following cardiac resynchronisation therapy. Objective  This monocenter observational study was designed to estimate the incidence of spontaneous conversion of persistent atrial fibrillation to SR in consecutive patients implanted with a cardiac resynchronisation device. Methods and results  A total of 46 patients with persistent atrial fibrillation (≥4 weeks pre-implant), left bundle branch block (QRS > 130 ms), left ventricular ejection fraction <0.35 and NYHA III or IV heart failure were implanted with a cardiac resynchronisation pacemaker or defibrillator and followed for at least 6 months between 6/2000 to 12/2006. During 22 ± 9 (7–34) months of follow-up, eight out of 46 patients (17%) converted to SR. Spontaneous conversion was encountered in seven cases, whereas one patient converted due to an ICD shock delivered for ventricular tachycardia; in the latter patient, previous ICD shocks had not converted atrial fibrillation. The time interval from device implantation to conversion was 12 ± 11 (3–31) months. In patients converting to SR, the duration of atrial fibrillation before device implantation was significantly shorter than in patients remaining in atrial fibrillation (15 ± 13 vs. 53 ± 58 months, P = 0.001). Echocardiographic parameters such as left ventricular ejection fraction, left ventricular enddiastolic diameter, left atrial diameter did not differ significantly between converting and non-converting patients. However, patients converting to SR showed a significant reduction in systolic pulmonary artery pressure on CRT vs. before CRT (45 ± 13 vs. 29 ± 5 mmHg, P = 0.008). Conclusions  This pilot study suggests that CRT favors spontaneous conversion of persistent AF to SR in a minority of patients. If confirmed by larger clinical studies, atrial lead implantation would be encouraged in these patients, in order to provide AV synchronous pacing in case of spontaneous conversion or successful cardioversion to SR on cardiac resynchronisation therapy. M. Hauck and A. Bauer contributed equally to this work.