Abstract

The ‘Happy Ending Problem’ in mathematics is the following statement: Any set of five points in the plane in a general position has a subset of four points that form the vertices of a convex quadrilateral .A particular analogy can be drawn between this so-called unsolved problem in mathematics and the still unsolved problem of treatment of patients with heart failure (HF) associated with atrial fibrillation. Patients with HF and atrial fibrillation represent a subgroup of patients that encounters additional difficulties when compared with patients in sinus rhythm (SR). Most available studies, which include this subgroup of patients, suggest a beneficial effect of cardiac resynchronization therapy (CRT) on the outcome ( Table 1 ).1–8 However, most studies in the field of CRT excluded this particular patient population. Moreover, studies until now have contained 95% of the patients in SR. Despite this, a few well-conducted studies have addressed this problem. Unfortunately, some studies have caused a certain amount of confusion because of controversial data. This controversy arises as a result of errors in the study design, interpretation, and the low inclusion rates. The above-mentioned analogy in mathematics clearly points out another difficulty in decision-making in this multifactorial problem. The five points in this geometrical problem can represent at least five independent factors, which could influence future recommendations. Furthermore, these factors could have a potential effect on the outcome: the effect of atrioventricular (AV) node ablation and pacing, the effect of the pacing site on cardiac function, a diminished atrial function (lack of atrial kick), the effect of rhythm regularization, and the presence … *Corresponding author. Tel: +31 104633991; fax: +36 12151220 ext. 413. E-mail address : t.szilitorok{at}erasmusmc.nl

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