We examined the long-term (≥ 5 years) outcomes of dual-site atrial pacing (DAP) when added to background antiarrhythmic drugs (AADs) and/or ablation in patients with refractory atrial fibrillation (AF) and heart failure (HF).

Seventy-three patients with HF (mean NYHA HF class of 2.5) and AF refractory to AADs and/or ablation were implanted with DAP systems to achieve biatrial electrical and mechanical resynchronization (ART) and rhythm control (RC).

Thirty-eight patients with refractory AF and HF with preserved ejection fraction (HFpEF) and 35 with reduced ejection fraction (HFrEF) were enrolled. HFpEF patients had higher left ventricular ejection fraction compared to HFrEF (53 ± 5 vs. 31 ± 10% p < 0.001). Median follow-up for survival was 9.3 years (mean 9.0 years, SE 0.63) and was similar across subgroups (p = 0.127). After DAP, 87% maintained RC with improvement in NYHA HF class (mean 1.8) at 3 years. RC was similar in HFpEF compared with HFrEF patients (89 vs. 85% respectively, p = NS) and in paroxysmal versus persistent AF (90 vs. 85% respectively, p = NS). Total survival was superior in HFpEF compared HFrEF patients (75% in HFpEF vs. 45% in HFrEF at 5 years, and 60% in HFpEF vs. 34% in HFrEF at 10 years, p = 0.036). Survival trended to be better in patients with RC than those without RC (75 vs. 54% respectively at 5 years, p = .13).

ART using DAP as add on therapy improved HF and established long-term RC in many patients with HFrEF and HFpEF with refractory AF. Long-term survival rates were superior in HFpEF than HFrEF.