Reverse Remodeling of the Left Cardiac Chambers After Catheter Ablation After 1 Year in a Series of Patients With Isolated Atrial Fibrillation Catheter ablation in selected patients with depressed left ventricular ejection fraction and persistent atrial fibrillation unresponsive to current cardioversion. Success of Ablation for Atrial Fibrillation in Isolated Left Ventricular Diastolic Dysfunction: A Comparison to Systolic Dysfunction and Normal Ventricular Function Pulmonary vein vestibule ablation for the control of atrial fibrillation in patients with impaired left ventricular function. A Randomized Controlled Trial of Catheter Ablation Versus Medical Treatment of Atrial Fibrillation in Heart Failure (The CAMTAF Trial) Efficacy, safety, and outcomes of catheter ablation of atrial fibrillation in patients with heart failure with preserved ejection fraction. Long-Term Improvement in Left Ventricular Strain After Successful Catheter Ablation for Atrial Fibrillation in Patients With Preserved Left Ventricular Systolic Function Ablation vs medical therapy in the setting of symptomatic atrial fibrillation and left ventricular dysfunction. Left ventricular systolic dysfunction by itself does not influence outcome of atrial fibrillation ablation Catheter ablation versus standard conventional treatment in patients with left ventricular dysfunction and atrial fibrillation (CASTLE-AF) - study design. Catheter ablation of paroxysmal atrial fibrillation improves cardiac function: a prospective study on the impact of atrial fibrillation ablation on left ventricular function assessed by magnetic resonance imaging. Catheter Ablation Versus Medical Rate Control in Atrial Fibrillation and Systolic Dysfunction: The CAMERA-MRI Study. Prognostic value of short-deceleration time of mitral inflow E velocity: implications in patients with atrial fibrillation and left-ventricular systolic dysfunction. Catheter ablation for atrial fibrillation results in greater improvement in cardiac function in patients with low versus normal left ventricular ejection fraction Comparison of usefulness of cardiac resynchronization therapy in patients with atrial fibrillation and heart failure versus patients with sinus rhythm and heart failure. A comparison of ventricular function during high right ventricular septal and apical pacing after his-bundle ablation for refractory atrial fibrillation. Urgent management of rapid heart rate in patients with atrial fibrillation/flutter and left ventricular dysfunction: comparison of the ultra-short-acting β1-selective blocker landiolol with digoxin (J-Land Study). Measuring left ventricular peak longitudinal systolic strain from a single beat in atrial fibrillation: validation of the index beat method. Right ventricular outflow versus apical pacing in pacemaker patients with congestive heart failure and atrial fibrillation. Clinical predictors of noninducibility of sustained atrial fibrillation after pulmonary vein isolation. Index-beat assessment of left ventricular systolic and diastolic function during atrial fibrillation using myocardial strain and strain rate. Pulmonary vein isolation for the treatment of atrial fibrillation in patients with impaired systolic function. Impaired left atrial function in heart failure with preserved ejection fraction.
Background — Isolated atrial fibrillation ( AF ) is associated with mild enlargement of the left atrium ( LA ) and left ventricular ( LV ) diastolic dysfunction . The impact of ablation of isolated AF on left chamber size and function is unclear , and whether diastolic dysfunction is the cause or the consequence of AF remains unknown . The objective of this prospect i ve study was to evaluate the impact of sinus rhythm restoration by catheter ablation on LV diastolic dysfunction , LA morphology , and mechanical function . Methods and Results — Forty-eight patients with isolated AF were studied by serial echocardiographic studies at baseline and at 1- , 3- , 6- , 9- , and 12-month intervals after radiofrequency ablation .  LA dimensions and mechanical function and LV systolic and diastolic functions were evaluated at each time interval . Diastolic function was assessed with conventional Doppler parameters and new indexes such as tissue Doppler imaging , mitral flow propagation velocity , and combined criteria . LV diastolic dysfunction was present in paroxysmal and chronic AF patients with a reduction of tissue Doppler imaging lateral early diastolic peak velocity in 37 % ( P<0.001 ) and 48 % ( P<0.01 ) , respectively , compared with healthy control subjects . At the end of the follow-up , LA area decreased significantly by 18 % ( P<0.001 ) in paroxysmal and 23 % ( P<0.05 ) in chronic AF patients . Diastolic function improved significantly with an increase in lateral early diastolic peak velocity of 29 % ( P<0.001 ) in paroxysmal AF and 46 % ( P<0.05 ) in chronic AF patients . A significant increase in LV ejection fraction was also noted for both groups : 7.7 % and 18.8 % , respectively . Conclusions — This study demonstrates reverse morphological remodeling of the LA and improvement of LV diastolic and systolic functions after restoration of sinus rhythm by ablation for isolated AF . Because patients with isolated AF have none of the traditional causes of LV diastolic dysfunction , our findings suggest that AF may be partly the cause rather than the consequence of diastolic dysfunction AIMS In congestive heart failure ( CHF ) patients with persistent atrial fibrillation ( AF ) , direct current cardioversion ( DCC ) may reveal participation of tachycardiamediated process to left ventricular ( LV ) dysfunction by restoring sinus rhythm ( SR ) . However , if DCC fails to restore SR , patients ' management remains challenging . The aim of the study was to assess the AF catheter ablation benefit in a selected group of CHF patients with LV ejection fraction ( LVEF ) < 40 % and persistent AF unresponsive to DCC , in whom a tachycardia-mediated process is thought to be predominant . METHODS AND RESULTS Between January 2008 and September 2011 , among 129 CHF patients with persistent AF referred to our institution , 34 ( 63.8 ± 9-year old , 24 men ) presented AF refractory to DCC with an estimated high likelihood of tachycardia-mediated LV dysfunction according to a specific set of criteria . These 34 patients underwent stepwise AF ablation and were closely followed up . After a mean 1.9 AF ablation procedures per patient and 17.6 ± 7 months after the last procedure , all patients were in SR . The New York Heart Association class improved from 2.8 ± 0.3 to 1 ± 0.2 ( P < 0.001 ) and the LVEF increased from 30.4 ± 6 to 54.6 ± 6 % ( P < 0.0001 ) after 3 - 6 months of SR , with a persistent benefit as long as the SR was maintained . CONCLUSION Atrial fibrillation catheter ablation in selected CHF patients with persistent AF refractory to DCC and without any other evidence for secondary LV dysfunction leads to a substantial LVEF improvement in the majority of them . However , redo procedures are frequent in order to achieve mid-term SR maintenance Background — The efficacy of radiofrequency ablation for atrial fibrillation ( AF ) in patients with left ventricular ( LV ) systolic dysfunction and isolated diastolic dysfunction is uncertain . Methods and Results — A prospect i ve cohort of patients with normal and abnormal LV function underwent ablation for antiarrhythmic drug (AAD)-refractory AF . Three groups were compared : 111 patients with systolic dysfunction , defined as LV ejection fraction ( LVEF ) ⩽40 % ; 157 patients with isolated diastolic dysfunction but preserved LVEF ≥50 % ; and 100 patients with normal LV function . The primary end point was AAD-free AF elimination at 1 year after ablation . This end point was achieved in 62 % of patients with systolic dysfunction , 75 % of those with diastolic dysfunction , and 84 % of controls ( P=0.007 ) . AF control on or off AADs was achieved in 76 % of patients with systolic dysfunction , 85 % of those with diastolic dysfunction , and 89 % of controls ( P=0.08 ) . In the systolic dysfunction group , 49 % experienced an increase in LVEF by ≥5 % after ablation , of which 64 % achieved normal LVEF . In the diastolic dysfunction group , 30 % of patients demonstrated at least 1 grade improvement in diastolic dysfunction . Multivariable analysis demonstrated an increased relative risk of arrhythmia recurrence of 1.8 ( 95 % CI , 1.1 to 3.1 ; P=0.02 ) in systolic dysfunction and 1.7 ( 1.0 to 2.7 ; P=0.04 ) in isolated diastolic dysfunction compared with normal function . Conclusions — Although an ablative approach for AF in patients with systolic or diastolic dysfunction is associated with an increased long-term recurrence risk , there is potential for substantial quality -of-life improvement and LV functional benefit INTRODUCTION Congestive heart failure ( CHF ) and atrial fibrillation ( AF ) are frequently linked , and when associated produce additive deleterious effects . In this prospect i ve study , the effects of catheter ablation for AF  in patients with impaired left ventricular ( LV ) function are presented . METHODS Baseline data and clinical outcome have been prospect ively collected in 105 consecutive patients who underwent pulmonary vein ablation for the control of AF .  We evaluated 40 patients affected by LV dysfunction with ejection fraction (EF)<40 % and compared them to the remaining 65 patients with normal ventricular function in terms of changes in LV function , maintenance of sinus rhythm , and quality of life during follow-up . RESULTS After a mean follow-up of 14+/-2 months , 87 % of patients with impaired LV function and 92 % of patients with normal ventricular function were in sinus rhythm , with or without antiarrhythmic therapy ( P = NS ) . A significant improvement in LVEF and fractional shortening was documented in patients with CHF ( 33+/-2 % vs 47+/-3 % , and 19+/-4 % vs 30+/-3 % , P<0.01 for both comparisons ) . Evaluation of exercise capacity and quality of life documented better improvements in patients with CHF compared to patients without CHF . CONCLUSIONS Catheter ablation in patients with LV dysfunction is feasible , not associated with higher procedural complications , and provides a significant improvement in LV performance , symptoms , and quality of life during follow-up Background —Restoring sinus rhythm in patients with heart failure ( HF ) and atrial fibrillation ( AF ) may improve left ventricular ( LV ) function and HF symptoms . We sought to compare the effect of a catheter ablation strategy with that of a medical rate control strategy in patients with persistent AF and HF . Methods and Results — Patients with persistent AF , symptomatic HF , and LV ejection fraction < 50 % were r and omized to catheter ablation or medical rate control . The primary end-point was the difference between groups in LV ejection fraction at 6 months . Baseline LV ejection fraction was 32±8 % in the ablation group and 34±12 % in the medical group . Twenty-six patients underwent catheter ablation  , and 24 patients were rate controlled .  Freedom from AF was achieved in 21/26 ( 81 % ) at 6 months off antiarrhythmic drugs . LV ejection fraction at 6 months in the ablation group was 40±12 % compared with 31±13 % in the rate control group ( P=0.015 ) . Ablation was associated with better peak oxygen consumption ( 22±6 versus 18±6 mL/kg per minute ; P=0.014 ) and Minnesota living with HF question naire score ( 24±22 versus 47±22 ; P=0.001 ) compared with rate control . Conclusions —Catheter ablation is effective in restoring sinus rhythm in selected patients with persistent AF and HF , and can improve LV function , functional capacity , and HF symptoms compared with rate control . Clinical Trial Registration —URL : http://www . clinical trials.gov . Unique identifier : OBJECTIVES This study sought to investigate the efficacy and safety of catheter ablation for atrial fibrillation ( AF ) in patients with heart failure with preserved ejection fraction ( HFPEF ) . BACKGROUND AF is a precipitating factor for clinical deterioration of HFPEF . METHODS Catheter ablation for AF was performed in a consecutive 74 patients with compensated HFPEF ( left ventricular [ LV ] ejection fraction > 50 % ) . AF-free probability after catheter ablation and factors relating to maintenance of sinus rhythm were investigated . LV strain and strain rate were assessed by echocardiography at baseline and over 12 months after ablation . RESULTS During a 34 ± 16-month follow-up period , single- and multiple-procedure drug-free success rates were 27 % ( n = 20 ) and 45 % ( n = 33 ) , respectively . Multiple procedures and pharmaceutically assisted success rate was 73 % ( n = 54 ) . No major complications occurred during follow-up . Multivariate Cox regression analyses revealed that AF type ( other than long-st and ing persistent AF ) and lack of hypertension were independently associated with maintenance of sinus rhythm ( hazard ratio [ HR ] : 1.81 , 95 % confidence interval [ CI ] : 1.03 to 3.17 , p = 0.04 ; HR : 0.49 , 95 % CI : 0.24 to 0.96 , p = 0.04 , respectively ) . LV systolic indices ( LV ejection fraction , LV strain/strain rate at systole ) and diastolic indices ( E/E ' , ratio of LV strain rate at diastole with early transmitral flow ) were improved only in patients maintaining sinus rhythm at follow-up . CONCLUSIONS Our results suggest that AF can be effectively and safely treated with a composite of repeat procedures and pharmaceuticals in patients with HFPEF . However , the current study was a single-arm analysis ; therefore , larger r and omized control studies are needed to verify the benefit of AF ablation in this cohort Background —The effect of successful catheter ablation on left ventricular ( LV ) strain in patients with preserved LV systolic function is unknown . The aim of the present study was to assess the long-term effects of catheter ablation for atrial fibrillation ( AF )  on LV strain and strain rate in patients with preserved LV ejection fraction . Methods and Results —In 78 patients undergoing catheter ablation for AF  , speckle tracking strain imaging was performed to assess LV strain in 3 directions ( radial , circumferential , and longitudinal ) at baseline and after 12-month follow-up . The study population was divided into 2 groups , according to the maintenance of sinus rhythm ( SR ) during follow-up . After 13.8±4.7 months of follow-up , 54 patients ( 69 % ) were in SR ( SR group ) , whereas 24 patients ( 31 % ) had recurrence of AF ( AF group ) . No significant changes in LV ejection fraction from baseline to follow-up were noted ( 60±7 % versus 59±7 % , P = NS ) . Circumferential strain improved significantly in the SR group ( −18.3±3.2 % versus −20.4±3.8 % , P<0.001 ) , whereas it remained unchanged in the AF group ( −18.9±3.5 % versus −17.9±3.1 % , P = NS ) . In the SR group , significant improvements in LV longitudinal strain and strain rate were noted , whereas in the AF group , LV longitudinal strain and strain rate deteriorated significantly at long-term follow-up . Conclusions —After successful catheter ablation , LV circumferential and longitudinal strain and strain rate improve significantly in patients who maintain SR . In contrast , a decrease in LV longitudinal strain and strain rate is observed in patients with recurrence of AF Small , single-center studies suggest that catheter ablation of atrial fibrillation ( AF )  can improve ventricular function and reduce symptoms in patients with left ventricular ( LV ) dysfunction . However , ablation has not been compared with a pharmacologic strategy for AF . The authors evaluated patients with AF and symptomatic LV dysfunction ( ejection fraction < or = 45 % ) referred for pulmonary vein isolation ( PVI ) . They compared these patients with a matched cohort treated medically for AF and LV dysfunction via a retrospective case-control method . Fifteen patients ( 14 men , 56+/-11 years , 10 [ 67 % ] paroxysmal AF ) with AF for 4+/-3 years underwent PVI .  Baseline ejection fraction was 37%+/-6 % and New York Heart Association ( NYHA ) class was 2.0+/-1.0 . Fifteen controls ( 13 men , 63+/-14 years , 11 [ 73 % ] paroxysmal AF ) with AF for 5+/-4 years were treated medically for AF . Baseline ejection fraction was 34%+/-11 % and NYHA class was 2.0+/-0.7 . The groups were similar in all respects . During a follow-up of 16+/-13 months after complete PVI , ejection fraction improved ( P=.001 ) to 50%+/-13 % and normalized in 8 patients ( 53 % ) . NYHA class improved to 1.3+/-0.5 ( P=.01 ) . In the medically treated group , after follow-up of 16+/-12 months , no improvement in ejection fraction ( 36%+/-12 % ) or NYHA class ( 1.8+/-0.7 ) was seen . Compared with pharmacologic therapy , PVI significantly improved LV function and NYHA class in patients with AF and symptomatic LV dysfunction . These provocative findings provide potent rationale for a r and omized clinical trial comparing ablation with pharmacologic therapy Aims The objective of the study was to analyse the influence of left ventricular ( LV ) ejection fraction ( EF ) on the outcomes of  atrial fibrillation ( AF ) ablation after a first procedure . Pre-procedural predictors of recurrences after AF ablation can be useful for patient information and selection of c and i date s. The independent influence of LV systolic dysfunction on recurrence rate has not been studied . Methods and results A case – control study ( 1:1 ) was conducted with a total of 72 patients : 36 cases ( depressed LVEF ) and 36 controls ( normal LVEF ) . Patients were matched by left atrial diameter ( LAD ) , the presence of arterial hypertension , and other variables that might influence the results ( age , gender and paroxysmal vs. persistent AF ) . There were no statistical differences in the variables used to perform the matching . Patients with depressed LVEF had higher LV end diastolic diameter ( 55.6 ± 6.2 vs. 52.4 ± 5.5 , P = 0.03 ) , higher LV end systolic diameter ( 40.3 ± 6.9 vs. 32.6 ± 4.3 , P < 0.001 ) , lower LVEF ( 41.4 ± 8.0 vs. 63.1 ± 5.5 , P < 0.001 ) and were more likely to have structural heart disease . After a mean follow-up of 16 ± 13 months , survival analysis for AF recurrences showed no differences between patients with depressed vs. normal LVEF ( 50.0 vs. 55.6 % , log rank = 0.82 ) . Cox regression analysis revealed LAD to be the only variable correlated to recurrence [ OR 1.11 ( 1.01–1.22 ) , P = 0.03 ] . Analysis at 6 months showed a significant increase in LVEF ( 43.23 ± 7.61 to 51.12 ± 13.53 % , P = 0.01 ) for the case group . Conclusion LV systolic dysfunction by itself is not a predictor of outcome after AF ablation . LAD independently correlates with outcome in patients with low or normal LVEF BACKGROUND Electrical isolation of the pulmonary veins by catheter ablation is an emerging treatment modality for the treatment of atrial fibrillation ( AF ) and is increasingly used in patients with heart failure . METHODS The catheter ablation versus st and ard conventional treatment in patients with left ventricular dysfunction and atrial fibrillation trial ( CASTLE-AF ) is a r and omized evaluation of ablative treatment of atrial fibrillation in patients with left ventricular dysfunction . The primary endpoint is the composite of all-cause mortality or worsening of heart failure requiring unplanned hospitalization using a time to first event analysis . Secondary endpoints are all-cause mortality , cardiovascular mortality , cerebrovascular accidents , worsening of heart failure requiring unplanned hospitalization , unplanned hospitalization due to cardiovascular reason , all-cause hospitalization , quality of life , number of therapies ( shock and antitachycardia pacing ) delivered by the implantable cardioverter-defibrillator ( ICD ) , time to first ICD therapy , number of device-detected ventricular tachycardia and ventricular fibrillation episodes , AF burden , AF free interval , left ventricular function , exercise tolerance , and percentage of right ventricular pacing . CASTLE-AF will r and omize 420 patients for a minimum of 3 years at 48 sites in the United States , Europe , Australia , and South America AIMS Beneficial effects of atrial fibrillation ( AF ) ablation have been demonstrated in patients with congestive heart failure ( CHF ) and significantly impaired left ventricular ejection fraction ( LVEF ) . However , the impact of pulmonary vein isolation ( PVI ) on cardiac function in patients with paroxysmal AF and impaired LVEF remains under discussion . This study aim ed to evaluate the impact of PVI for paroxysmal AF on cardiac function in patients with impaired LVEF using cardiac magnetic resonance imaging ( CMRI ) . METHODS AND RESULTS A total number of 70 patients with paroxysmal AF and episodes < or = 24 h were  scanned on a 1.5-T-CMRI before and 6 months after PVI during sinus rhythm . End-diastolic volume , end-systolic volume , and LVEF were determined by epicardial and endocardial measurements . Patients were categorized into two groups regarding cardiac function as assessed by CMRI : group 1 patients ( n = 18 ) with an LVEF < 50 % and patients with an LVEF > 50 % ( group 2 , n = 52 ) . Group 1 patients demonstrated a significant lower success rate than patients of group 2 after a follow-up of 152 + /- 40 days ( 50 vs. 73 % , P < 0.05 ) . Cardiac magnetic resonance imaging in group 1 patients demonstrated a significant improvement in cardiac function after AF ablation ( 41 + /- 6 vs. 51 + /- 12 % , P = 0.004 ) , whereas group 2 patients did not show significant differences ( 60 + /- 6 vs. 59 + /- 9 % , P = 0.22 ) after a 6 months follow-up . CONCLUSION Pulmonary vein isolation improves cardiac function in patients with paroxysmal AF and impaired LVEF . These data suggest that an impaired LV function can be partially attributed to AF with short-lasting paroxysms BACKGROUND Atrial fibrillation ( AF ) and left ventricular systolic dysfunction ( LVSD ) frequently co-exist despite adequate rate control . Existing r and omized studies of AF and LVSD of varying etiologies have reported modest benefits with a rhythm control strategy . OBJECTIVES The goal of this study was to determine whether catheter ablation ( CA ) for AF could improve LVSD compared with medical rate control ( MRC ) where the etiology of the LVSD was unexplained , apart from the presence of AF . METHODS This multicenter , r and omized clinical trial enrolled patients with persistent AF and idiopathic cardiomyopathy ( left ventricular ejection fraction [ LVEF ] ≤45 % ) . After optimization of rate control , patients underwent cardiac magnetic resonance ( CMR ) to assess LVEF and late gadolinium enhancement , indicative of ventricular fibrosis , before r and omization to either CA or ongoing MRC . CA included pulmonary vein isolation and posterior wall isolation . AF burden post-CA was assessed by using an implanted loop recorder , and adequacy of MRC was assessed by using serial Holter monitoring . The primary endpoint was change in LVEF on repeat CMR at 6 months . RESULTS A total of 301 patients were screened ; 68 patients were enrolled between November 2013 and October 2016 and r and omized with 33 in each arm ( accounting for 2 dropouts ) .  The average AF burden post-CA was 1.6 ± 5.0 % at 6 months . In the intention-to-treat analysis , absolute LVEF improved by 18 ± 13 % in the CA group compared with 4.4 ± 13 % in the MRC group ( p < 0.0001 ) and normalized ( LVEF ≥50 % ) in 58 % versus 9 % ( p = 0.0002 ) . In those undergoing CA , the absence of late gadolinium enhancement predicted greater improvements in absolute LVEF ( 10.7 % ; p = 0.0069 ) and normalization at 6 months ( 73 % vs. 29 % ; p = 0.0093 ) . CONCLUSIONS AF is an underappreciated reversible cause of LVSD in this population despite adequate rate control . The restoration of sinus rhythm with CA results in significant improvements in ventricular function , particularly in the absence of ventricular fibrosis on CMR . This outcome challenges the current treatment paradigm that rate control is the appropriate strategy in patients with AF and LVSD . ( Catheter Ablation Versus Medical Rate Control in Atrial Fibrillation and Systolic Dysfunction [ CAMERA-MRI ] ; ACTRN12613000880741 ) OBJECTIVE The aim of this prospect i ve study was to evaluate the contribution of an initially shortened deceleration time of mitral inflow E velocity ( E-wave DT ) to predict survival in patients with left-ventricular ( LV ) systolic dysfunction in atrial fibrillation ( AF ) and in sinus rhythm ( SR ) .  BACKGROUND To date , few data are available concerning the prognostic value of Doppler mitral profile in patients with AF , particularly in the presence of LV systolic dysfunction . METHODS We studied the outcome of 140 consecutive patients with LV ejection fraction less than 40 % . Complete history , physical examination and echocardiography were performed . RESULTS  Chronic AF  was present in 40 ( 29 % ) patients . Over a mean follow-up of 25+/-11 months , 54 ( 39 % ) patients died , 18 in the AF group and 36 in the SR group . Ejection fraction was similar in the two groups ( 31 % versus 32 % , respectively ) . Survival curves indicated a significantly poorer prognosis for shortened E-wave DT less than 150 ms in the AF group and in the SR group ( both p < or=0.01 ) . Using multivariable Cox analysis , shortened E-wave DT was identified as an independent predictor of mortality in the AF group ( exponential of coefficient : 0.97 ; chi-square : 5.82 ; p=0.01 ) and in the SR group ( exponential of coefficient : 0.98 ; chi-square : 5.82 ; p=0.001 ) . CONCLUSION In patients with LV systolic dysfunction , a shortened deceleration time E-wave on Doppler examination appears to predict a similar poor prognosis in patients with AF as with SR Purpose It is still unknown whether left ventricular ejection fraction ( LVEF ) might affect the magnitude of improvement after atrial fibrillation ( AF ) ablation on cardiac function in persistent or longst and ing persistent AF ( CAF ) patients . Method We performed echocardiography in 35 patients with CAF before and after catheter ablation ( CA ) .  Patients were stratified by LVEF into two groups prior to CA — normal LVEF ( ≥50 % LVEF , N group , n = 24 ) and a low LVEF group ( < 50 % LVEF , L group , n = 11 ) . Patients were followed at 1 month , 3 months , 6 months , 1 year , and 2 years after ablation . Results After 15.8 ± 7.4 months follow-up , the L group showed greater improvement in LVEF and left atrial ejection fraction ( LAEF ; N group vs L group : LVEF difference ( % ) , 5 ±8 vs 20± 13 , p < 0.01 ; LAEF difference ( % ) , 11 ± 12 vs 21 ± 10 , p < 0.05 ) . LA maximal volume and E/e′ showed the same tendency after ablation , although the extent of improvement was not statistically significant . Both groups showed almost the same time course of improvement up to 2 years , although the L group showed earlier recovery in LVEF . Conclusion The greater improvement in several cardiac functions was seen in patients with greater LV dysfunction , after the CA for CAF The prevalence of atrial fibrillation ( AF ) in patients with heart failure is high , but data about the effects of cardiac resynchronization therapy ( CRT ) in patients with chronic AF are scarce . In this prospect i ve observational study of 263 consecutive patients , CRT was performed in 96 patients ( 37 % ) with chronic AF and 167 patients ( 63 % ) with sinus rhythm ( SR ) .  Echocardiographic and clinical parameters were evaluated at baseline and 3 and 12 months . Reverse left ventricular ( LV ) remodeling is defined as LV end-systolic volume decrease > or = 10 % . Hospitalization rates for heart failure in the year before and after implantation were compared . Baseline characteristics between patients with and without AF were similar , but the AF group had smaller LV end-systolic and end-diastolic volumes and larger left atrial dimensions . New York Heart Association class , 6-minute walking distance , quality -of-life score , LV ejection fraction , and mitral regurgitation improved significantly at 3 and 12 months in both groups , and the changes were similar . Reverse LV remodeling after 3 and 12 months was 74 % and 82 % ( AF group ) versus 77 % and 83 % , respectively ( SR group , p = 0.79 ) . After 1 year , cardioversion had occurred in 25 % of patients with AF . In the year after implantation , significant decreases in hospitalizations for heart failure in both groups ( 84 % and 90 % ) were documented . Long-term mortality was almost equal in both groups . In conclusion , this large-scale study shows that the benefit of CRT in patients with chronic AF and heart failure is similar to that in patients with SR . Patients with chronic AF and heart failure should be considered c and i date s for CRT This study compares LV performance during high right ventricular septal ( RVS ) and apical ( RVA ) pacing in patients with LV dysfunction who underwent His-bundle ablation for chronic AF . We inserted a passive fixation pacing electrode into the RVA and an active fixation electrode in the RVS . A dual chamber , rate responsive pulse generator stimulated the RVA through the ventricular port and the RVS via the atrial port . Patients were r and omized to initial RVA ( VVIR ) or RVS ( AAIR ) pacing for 2 months . The pacing site was reversed during the next 2 months . At the 2 and 4 month follow-up visit , each patient underwent a transthoracic echocardiographical study and a rest/exercise first pass radionuclide ventriculogram . We studied nine men and three women ( mean age of 68 + /- 7 years ) with congestive heart failure functional Class ( NYHA Classification ) : I ( 3 patients ) , II ( 7 patients ) , and III ( 2 patients ) . The QRS duration was shorter during RVS stimulation ( 158 + /- 10 vs 170 + /- 11 ms , P < 0.001 ) . Chronic capture threshold and lead impedance did not significantly differ . LV fractional shortening improved during RVS pacing ( 0.31 + /- 0.05 vs 0.26 + /- 0.07 , P < 0.01 ) . RVS activation increased the resting first pass LV ejection fraction ( 0.51 + /- 0.14 vs 0.43 + /- 0.10 , P < 0.01 ) . No significant difference was observed during RVS and RVA pacing in the exercise time ( 5.6 + /- 3.2 vs 5.4 + /- 3.1 , P = 0.6 ) or the exercise first pass LV ejection fraction ( 0.58 + /- 0.15 vs 0.55 + /- 0.16 , P = 0.2 ) . The relative changes in QRS duration and LV ejection fraction at both pacing sites showed a significant correlation ( P < 0.01 ) . We conclude that RVS pacing produces shorter QRS duration and better chronic LV function than RVA pacing in patients with mild to moderate LV dysfunction and chronic AF after His-bundle ablation BACKGROUND A rapid heart rate ( HR ) during atrial fibrillation ( AF ) and atrial flutter ( AFL ) in left ventricular ( LV ) dysfunction often impairs cardiac performance . The J-L and study was conducted to compare the efficacy and safety of l and iolol , an ultra-short-acting β-blocker , with those of digoxin for swift control of tachycardia in AF/AFL in patients with LV dysfunction . METHODS AND RESULTS The 200 patients with AF/AFL , HR ≥120beats/min , and LV ejection fraction 25 - 50 % were r and omized to receive either l and iolol ( n=93 ) or digoxin ( n=107 ) . Successful HR control was defined as ≥20 % reduction in HR together with HR < 110beats/min at 2h after starting intravenous administration of l and iolol or digoxin . The dose of l and iolol was adjusted in the range of 1 - 10µg·kg(-1)·min(-1 ) according to the patient 's condition . The mean HR at baseline was 138.2±15.7 and 138.0±15.0beats/min in the l and iolol and digoxin groups , respectively . Successful HR control was achieved in 48.0 % of patients treated with l and iolol and in 13.9 % of patients treated with digoxin  ( P<0.0001 ) . Serious adverse events were reported in 2 and 3 patients in each group , respectively . CONCLUSIONS L and iolol was more effective for controlling rapid HR  than digoxin in AF/AFL patients with LV dysfunction , and could be considered as a therapeutic option in this clinical setting BACKGROUND It is traditionally difficult to estimate left ventricular ( LV ) systolic function in atrial fibrillation ( AF ) . The aim of this study was to vali date the use of an index beat , the beat after the nearly equal preceding ( RR1 ) and pre-preceding ( RR2 ) intervals , for the measurement of LV peak longitudinal systolic strain ( PLSS ) . The difference between RR1 and RR2 intervals of the index beat must be < 60 msec . LV PLSS measured from the index beat ( PLSSindex ) was compared with LV PLSS measured from the conventional but time-consuming method of averaging multiple cardiac cycles ( PLSSavg ) . METHODS Ninety-eight patients with persistent or permanent AF and resting ventricular rates ≤ 105 beats/min were prospect ively included .  LV PLSSindex and LV PLSSavg were obtained from two-dimensional speckle-tracking echocardiography . RESULTS LV PLSSindex had a highly significant correlation with LV PLSSavg ( r = 0.970 , P < .001 ) . Bl and -Altman analysis showed only small bias of 0.01 % , and the 95 % limits of agreement were + 1.64 % to -1.62 % . Compared with those with lower risk scores of stroke indicated by CHADS(2 ) scores < 2 or CHA(2)DS(2)-VASc scores < 2 , patients with higher risk scores of stroke indicated by CHADS(2 ) scores ≥ 2 or CHA(2)DS(2)-VASc scores ≥ 2 had lower PLSSavg and PLSSindex ( P ≤ .012 ) . CONCLUSIONS LV PLSSindex was a good alternative to LV PLSSavg in patients with AF . Use of the index beat to measure LV longitudinal systolic strain in patients with AF was as accurate as the time-consuming method of averaging multiple cardiac cycles INTRODUCTION Prior studies suggest that right ventricular apical ( RVA ) pacing has deleterious effects . Whether the right ventricular outflow tract ( RVOT ) is a more optimal site for permanent pacing in patients with congestive heart failure ( CHF ) has not been established . METHODS AND RESULTS We conducted a r and omized , cross-over trial to determine whether quality of life ( QOL ) is better after 3 months of RVOT than RVA pacing in 103 pacemaker recipients with CHF , left ventricular ( LV ) systolic dysfunction ( LV ejection fraction < or = 40 % ) , and chronic atrial fibrillation ( AF ) . An additional aim was to compare dual-site ( RVOT + RVA , 31-ms delay ) with single-site RVA and RVOT pacing .  QRS duration was shorter during RVOT ( 167 + /- 45 ms ) and dual-site ( 149 + /- 19 ms ) than RVA pacing ( 180 + /- 58 ms , P < 0.0001 ) . At 6 months , the RVOT group had higher ( P = 0.01 ) role-emotional QOL subscale scores than the RVA group . At 9 months , there were no significant differences in QOL scores between RVOT and RVA groups . Comparing RVOT to RVA pacing within the same patient , mental health subscale scores were better ( P = 0.03 ) during RVOT pacing . After 9 months of follow-up , LVEF was higher ( P = 0.04 ) in those assigned to RVA rather than RVOT pacing between months 6 and 9 . After 3 months of dual-site RV pacing , physical functioning was worse ( P = 0.04 ) than during RVA pacing , mental health was worse ( P = 0.02 ) than during RVOT pacing , and New York Heart Association ( NYHA ) functional class was slightly better ( P = 0.03 ) than during RVOT pacing . There were no other significant differences between RVA , RVOT and dual-site RV pacing in QOL scores , NYHA class , distance walked in 6 minutes , LV ejection fraction , or mitral regurgitation . CONCLUSION In patients with CHF , LV dysfunction , and chronic AF , RVOT and dual-site RV pacing shorten QRS duration but after 3 months do not consistently improve QOL or other clinical outcomes compared with RVA pacing BACKGROUND Noninducibility of  sustained atrial fibrillation ( AF ) after pulmonary vein isolation ( PVI )  has been shown to be associated with a better clinical outcome . We evaluated the role of clinical variables that could predict noninducibility of sustained AF after PVI . METHODS AND RESULTS Data were collected prospect ively from 181 patients ( 153 male ; age 54 + /- 9 years ) referred for ablation of drug-refractory symptomatic paroxysmal AF ( duration < or = 7 days ) . Clinical variables were evaluated with regard to their ability of predicting noninducibility of sustained AF  ( < or = 10 minutes ) after PVI . Univariate analysis was performed on all collected variables followed by multivariate analysis for variables showing a P value < 0.1 . After PVI , sustained AF was noninducible in 97 ( 54 % ) patients . The following clinical variables showed a significant difference between the groups : body weight , longest AF episode , duration of AF history , presence or absence of structural heart disease , left ventricular ( LV ) hypertrophy , prior cardioversion , left atrial ( LA ) parasternal , and longitudinal diameters and LV diameters . On multivariate analysis , three independent predictors of noninducibility were identified : a shorter duration of AF episodes ( AF < 12 hours : RR 0.01 ( 0.002 - 0.06 ) , P < 0.001 ; AF 12 - 48 hours : RR 0.07 ( 0.01 - 0.37 ) , P = 0.001 ) ; LA longitudinal diameter < 57 mm ( RR 0.33 ( 0.13 - 0.82 ) , P = 0.016 ) ; and absence of LV hypertrophy ( RR 0.15 ( 0.04 - 0.63 ) , P = 0.01 ) . CONCLUSIONS Shorter AF episodes , smaller LA longitudinal diameter , and absence of LV hypertrophy are independent predictors of noninducibility of sustained AF after PVI BACKGROUND Accurate assessment of left ventricular ( LV ) function in patients with atrial fibrillation ( AF ) remains difficult , mainly because of the beat-to-beat variability of many echocardiographic parameters . The aim of this study was to assess the hypothesis that LV function can be estimated from an index-beat echocardiographic assessment in patients with AF using myocardial strain and strain rate . METHODS A prospect i ve study was conducted to assess 25 patients with AF ( mean age , 66 ± 10 years ) . Peak systolic longitudinal strain ( LS ) and peak diastolic longitudinal strain rate ( dSR ) were measured using two different methods : ( 1 ) mean LS and dSR , the averages of instantaneous LS and dSR over 10 sec , and ( 2 ) index-beat LS and dSR , calculated when the ratio of the preceding ( RR1 ) to the pre-preceding ( RR2 ) interval was 1 ( range , 0.96 - 1.04 ) . These variables were compared with simultaneously measured LV pressure parameters using Millar catheters . RESULTS There was a positive linear relationship between mean LS and index-beat LS at RR1/RR2 = 1 ( r = 0.94 , P < .001 ) and a positive linear relationship between mean dSR and index-beat dSR ( r = 0.69 , P < .001 ) . Index-beat LS was correlated with the maximal positive derivative of LV pressure ( peak + dP/dt ) ( r = -0.73 , P < .001 ) . Index-beat dSR was correlated with the time constant of isovolumic LV pressure decay ( τ ) ( r = -0.63 , P < .001 ) . To investigate the independent predictors of τ , a stepwise multilinear regression analysis showed that index-beat dSR was the best predictor of τ . CONCLUSIONS Index-beat parameters accurately reflect the mean values of parameters in patients with AF . These noninvasively obtained index-beat parameters are useful to assess surrogate LV function even in patients with AF OBJECTIVES We aim ed to determine the safety and efficacy of pulmonary vein isolation ( PVI ) in atrial fibrillation ( AF ) patients with impaired left ventricular ( LV ) systolic function . BACKGROUND To date , PVI has been performed primarily in patients with normal LV function . Yet , many AF patients have impaired LV systolic function . The outcomes of PVI in patients with impaired LV systolic function are unknown . METHODS We included 377 consecutive patients undergoing PVI between December 2000 and January 2003 . Ninety-four patients had impaired LV function ( ejection fraction [ EF ] < 40 % ) , and they comprised the study group . The control group was the remaining 283 patients who had a normal EF . End points included AF recurrence and changes in EF and quality of life ( QoL ) . RESULTS Mean EF was 36 % in our study group , compared with 54 % in controls . After initial PVI , 73 % of patients with impaired EF and 87 % of patients with normal EF were free of AF recurrence at 14 + /- 6 months ( p = 0.03 ) . In the study group , there was a nonsignificant increase in EF of 4.6 % and significant improvement in QoL. Complication rates were low and included a 1 % risk of pulmonary vein stenosis . CONCLUSIONS Although the AF recurrence rate after initial PVI in impaired EF patients was higher than in normal EF subjects , nearly three-fourths of patients with impaired EF remained AF-free . Although our sample size was nonr and omized , our results suggest PVI may be a feasible therapeutic option in AF patients with impaired EF . R and omized studies with more patients and longer follow-up are warranted AIMS Left atrial ( LA ) enlargement is present in the majority of heart failure with preserved ejection fraction ( HFpEF ) patients and is a marker of risk . However , the importance of LA function in HFpEF is less well understood . METHODS AND RESULTS The PARAMOUNT trial enrolled HFpEF patients ( LVEF ≥45 % , NT-proBNP > 400 pg/mL ) . We assessed LA reservoir , conduit , and pump function using two-dimensional volume indices and speckle tracking echocardiography in 135 HFpEF patients in sinus rhythm at the time of echocardiography and 40 healthy controls of similar age and gender . Systolic LA strain was related to clinical characteristics and measures of cardiac structure and function . Compared with controls , HFpEF patients had worse LA reservoir , conduit , and pump function . The differences in systolic LA strain ( controls 39.2 ± 6.6 % vs. HFpEF 24.6 ± 7.3 % ) between groups remained significant after adjustments and even in the subsets of HFpEF patients with normal LA size or without a history of AF . Among HFpEF patients , lower systolic LA strain was associated with higher prevalence of prior HF hospitalization and history of AF , as well as worse LV systolic function , and higher LV mass and LA volume . However , NT-proBNP and E/E ' were similar across the quartiles of LA function . CONCLUSIONS In this HFpEF cohort , we observed impairment in all phases of LA function , and systolic LA strain was decreased independent of LA size or history of AF . LA dysfunction may be a marker of severity and play a pathophysiological role in HFpEF . TRIAL REGISTRATION NCT00887588
AF ablation in patients with systolic LV dysfunction results in significant improvement of LV function , but the extent of this improvement is heterogeneous .
Patients with coronary artery disease seem to benefit less than patients with other underlying diseases .
These results may be explained by patient selection
BACKGROUND Atrial fibrillation ( AF ) and heart failure are often coexisting major public health burdens .
Although several studies have reported partial restoration of systolic left ventricular ( LV ) function after catheter ablation for AF , the method is not widely applied in patients with LV dysfunction .
We review ed the results of AF ablation in patients with systolic LV dysfunction .