A strategy to achieve CRT response in permanent atrial fibrillation without obligatory atrioventricular node ablation. Four-year efficacy of cardiac resynchronization therapy on exercise tolerance and disease progression: the importance of performing atrioventricular junction ablation in patients with atrial fibrillation. Outcomes of cardiac resynchronization therapy in patients with intermittent atrial fibrillation or atrial flutter in the COMPANION trial. Ablation Versus Amiodarone for Treatment of Persistent Atrial Fibrillation in Patients With Congestive Heart Failure and an Implanted Device: Results From the AATAC Multicenter Randomized Trial Cardiac resynchronization therapy in patients with atrial fibrillation: a 2-year follow-up study. A Randomized Controlled Trial of Catheter Ablation Versus Medical Treatment of Atrial Fibrillation in Heart Failure (The CAMTAF Trial) Ablation vs medical therapy in the setting of symptomatic atrial fibrillation and left ventricular dysfunction. Atrioventricular nodal ablation predicts survival benefit in patients with atrial fibrillation receiving cardiac resynchronization therapy. Mortality After Atrioventricular Nodal Radiofrequency Catheter Ablation With Permanent Ventricular Pacing in Atrial Fibrillation: Outcomes From a Controlled Nonrandomized Study Efficacy, safety, and outcomes of catheter ablation of atrial fibrillation in patients with heart failure with preserved ejection fraction. Catheter ablation versus standard conventional treatment in patients with left ventricular dysfunction and atrial fibrillation (CASTLE-AF) - study design. Long-term effects of cardiac resynchronisation therapy in patients with atrial fibrillation A randomized trial to assess catheter ablation versus rate control in the management of persistent atrial fibrillation in heart failure. Atrial fibrillation in patients with heart failure: Role of catheter ablation therapies. Effect of Cardiac Resynchronization on the Incidence of Atrial Fibrillation in Patients With Severe Heart Failure Sudden death after radiofrequency ablation of the atrioventricular node in patients with atrial fibrillation. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Catheter ablation for atrial fibrillation results in greater improvement in cardiac function in patients with low versus normal left ventricular ejection fraction Rationale and Design of FIRE AND ICE: A multicenter randomized trial comparing efficacy and safety of pulmonary vein isolation using a cryoballoon versus radiofrequency ablation with 3D-reconstruction. Sinus rhythm restoration by catheter ablation in patients with long-lasting atrial fibrillation and congestive heart failure: impact of the left ventricular ejection fraction improvement on the implantable cardioverter defibrillator insertion indication. Catheter Ablation Versus Medical Rate Control in Atrial Fibrillation and Systolic Dysfunction: The CAMERA-MRI Study. Clinical outcomes of catheter substrate ablation for high-risk patients with atrial fibrillation. Pulmonary-vein isolation for atrial fibrillation in patients with heart failure.
BACKGROUND Cardiac resynchronization therapy ( CRT ) is an established method in patients with severe heart failure and wide QRS configuration , particularly during sinus rhythm ( SR ) . In CRT patients with permanent atrial fibrillation ( AF ) , there is no general consensus regarding the need for atrioventricular node ( AVN ) ablation . The aim of this study was to evaluate the benefit of CRT in permanent AF with and without AVN ablation . METHODS New York Heart Association classification , QRS duration , and echocardiographic parameters were assessed before and after CRT with a follow-up of 12 ± 3 months . Two hundred thirty patients in SR and 46 patients with permanent AF of 2.1 ± 0.5 years duration were studied .  AVN ablation was performed only in AF patients with insufficient pharmacological rate control evidence d by ≤80 % ventricular stimulation . RESULTS Fifteen AF patients underwent AVN ablation . Biventricular pacing comparably improved functional status , left ventricular ejection fraction , and left ventricular end-diastolic dimensions in all treated groups . Biventricular stimulation percentage was 10 % lower in pharmacologically treated AF patients over 1 year as compared to patients in SR and to AF patients undergoing AVN ablation , which did not affect outcome in this patient population . CONCLUSION In patients with permanent AF and CRT , an AVN ablation strategy might not be strictly required in all patients OBJECTIVES The goal of this study was to investigate the effects of cardiac resynchronization therapy ( CRT ) in heart failure patients with permanent atrial fibrillation ( AF ) and the role of atrioventricular junction ( AVJ ) ablation . BACKGROUND Cardiac resynchronization therapy has been proven effective in heart failure patients with sinus rhythm ( SR ) . However , little is known about the effects of CRT in heart failure patients with permanent AF . METHODS Efficacy of CRT on ventricular function , exercise performance , and reversal of maladaptive remodeling process was prospect ively compared in 48 patients with permanent AF in whom ventricular rate was controlled by drugs , thus result ing in apparently adequate delivery of biventricular pacing ( > 85 % of pacing time ) , and in 114 permanent AF patients , who had undergone AVJ ablation ( 100 % of resynchronization therapy delivery ) . The clinical and echocardiographic long-term outcomes of both groups were compared with those of 511 SR patients treated with CRT . RESULTS Both SR and AF groups showed significant and sustained improvements of all assessed parameters ( model p < 0.001 for all parameters ) . However , within the AF group , only patients who underwent ablation showed a significant increase of ejection fraction ( p < 0.001 ) , reverse remodeling effect ( p < 0.001 ) , and improved exercise tolerance ( p < 0.001 ) ; no improvements were observed in AF patients who did not undergo ablation . CONCLUSIONS Heart failure patients with ventricular conduction disturbance and permanent AF treated with CRT showed large and sustained long-term ( up to 4 year ) improvements of left ventricular function and functional capacity , similar to patients in SR , only if AVJ ablation was performed BACKGROUND Controlled clinical trial data are lacking for cardiac resynchronization therapy ( CRT ) outcomes in patients with advanced heart failure ( HF ) from reduced left ventricular ejection fraction ( HFrEF ) and intermittent atrial fibrillation or flutter ( IAF/AFL ) . OBJECTIVE The purpose of this study was to describe CRT outcomes in patients with IAF/AFL and advanced HF . METHODS HF outcomes in patients in the COMPANION ( Comparison of Medical Therapy , Pacing , and Defibrillation in Heart Failure ) trial with New York Heart Association class III or IV HFrEF , left ventricular ejection fraction ≤0.35 , sinus rhythm at r and omization , and no history of baseline arrhythmia were compared with those with a history of IAF/AFL . RESULTS In those with no history of baseline arrhythmia ( n = 887 ) , compared with optimal pharmacological therapy ( OPT ) with no CRT , the CRT + OPT arms exhibited a significant reduction in the end points of death or any hospitalization ( hazard ratio [ HR ] 0.73 [ 95 % Confidence Interval ( CI ) : 0.60 to 0.89 ] ; P = .002 ) and death or HF hospitalization ( HR 0.53 [ 95 % CI : 0.41 to 0.68 ] ; P < .001 ) . In contrast , in the IAF/AFL subgroup ( n = 293 ) , CRT did not result in improved outcomes compared with OPT ( death or any hospitalization : HR 1.16 [ 95 % CI : 0.83 to 1.63 ] ; P = .38 ; death or HF hospitalization : HR 0.97 [ 95 % CI : 0.64 to 1.46 ] ; P = .88 ) . The interaction between history of AF/AFL and CRT was statistically significant for both outcomes ( P < .05 ) . CONCLUSION In the COMPANION trial , patients with moderate to severe HFrEF and a history of IAF/AFL had no benefit from CRT Background — Whether catheter ablation ( CA ) is superior to amiodarone ( AMIO ) for the treatment of persistent atrial fibrillation ( AF ) in patients with heart failure is unknown . Methods and Results — This was an open-label , r and omized , parallel-group , multicenter study . Patients with persistent AF , dual-chamber implantable cardioverter defibrillator or cardiac resynchronization therapy defibrillator , New York Heart Association II to III , and left ventricular ejection fraction < 40 % within the past 6 months were r and omly assigned ( 1:1 ratio ) to undergo CA for AF ( group 1 , n=102 ) or receive AMIO ( group 2 , n=101 ) . Recurrence of AF was the primary end point . All-cause mortality and unplanned hospitalization were the secondary end points . Patients were followed up for a minimum of 24 months . At the end of follow-up , 71 ( 70 % ; 95 % confidence interval , 60%–78 % ) patients in group 1 were recurrence free after an average of 1.4±0.6 procedures in comparison with 34 ( 34 % ; 95 % confidence interval , 25%–44 % ) in group 2 ( log-rank P<0.001 ) . The success rate  of CA in the different centers after a single procedure ranged from 29 % to 61 % . After adjusting for covariates in the multivariable model , AMIO therapy was found to be significantly more likely to fail ( hazard ratio , 2.5 ; 95 % confidence interval , 1.5–4.3 ; P<0.001 ) than CA . Over the 2-year follow-up , the unplanned hospitalization rate was ( 32 [ 31 % ] in group 1 and 58 [ 57 % ] in group 2 ; P<0.001 ) , showing 45 % relative risk reduction ( relative risk , 0.55 ; 95 % confidence interval , 0.39–0.76 ) . A significantly lower mortality was observed in CA ( 8 [ 8 % ] versus AMIO ( 18 [ 18 % ] ; P=0.037 ) . Conclusions — This multicenter r and omized study shows that CA of AF is superior to AMIO in achieving freedom from AF at long-term follow-up and reducing unplanned hospitalization and mortality in patients with heart failure and persistent AF . Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT00729911 INTRODUCTION Atrial fibrillation ( AF ) is the most common arrhythmia in patients with heart failure ( HF ) and represents an important comorbidity in these patients . Cardiac resynchronization therapy ( CRT ) has been shown to be beneficial in patients with HF . Whether patients with AF benefit similarly from CRT as their counterparts in sinus rhythm is controversial . METHODS AND RESULTS We conducted a cohort analysis of 175 patients ( 138 men ; age range 57 - 79 years ) who underwent CRT implantation during 2004 - 2008 in our institution . AF was documented in 66 patients ( 37.7 % of patients , 52 men ) . There were no differences in 1- or 2-year mortality between patients with and without AF ( 13.6 % vs 11.79 % , P = 0.7 ; 25.8 % vs 16.9 % , P = 0.2 , respectively ) . There were no differences between the groups in the rate of complications after CRT implantation or in the rate of appropriate electrical shocks . In the subgroup of AF patients with cardiac resynchronization therapy defibrillator ( CRT-D ) ( n = 32 , 48.5 % ) , the 1-year mortality was 3.1 % as compared to 23.5 % in AF patients with cardiac resynchronization therapy pacemaker ( P = 0.03 ) . This difference was no longer evident after 2 years ( 25.0 % vs 26.5 % , P = 0.8 , respectively ) . Ten patients ( 15.2 % ) with AF underwent atrioventricular ( AV ) node ablation . The 2-year mortality of these patients was 10.0 % as compared to 28.6 % in AF patients who did not undergo AV-node ablation ( P = 0.4 ) . CONCLUSIONS In this study , no difference in mortality appears to exist between patients with or without AF and who undergo CRT implantation . Our findings of the beneficial effects of AV-node ablation and CRT-D in AF patients deserve further investigation 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 : 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 BACKGROUND Cardiac resynchronization therapy ( CRT ) benefits patients with advanced heart failure . The role of atrioventricular nodal ( AVN ) ablation in improving CRT outcomes , including survival benefit in CRT recipients with atrial fibrillation , is uncertain . OBJECTIVE The purpose of this study was to assess the impact of AVN ablation on clinical and survival outcomes in a large atrial fibrillation and heart failure population that met the current indication for CRT and to determine whether AVN ablation is an independent predictor of survival in CRT recipients . METHODS Of 154 patients with atrial fibrillation who received CRT-D , 45 ( 29 % ) underwent AVN ablation ( + AVN-ABL group ) , whereas 109 ( 71 % ) received drug therapy for rate control during CRT ( -AVN-ABL group ) . New York Heart Association ( NYHA ) class , electrocardiogram , and echocardiogram were assessed before and after CRT .  Survival data were obtained from the national death and location data base ( Accurint ) . RESULTS CRT comparably improved left ventricular ejection fraction ( 8.1 % + /- 10.7 % vs 6.8 % + /- 9.6 % , P = .49 ) and left ventricular end-diastolic diameter ( -2.1 + /- 5.9 mm vs -2.1 + /- 6.7 mm , P = .74 ) in both + AVN-ABL and -AVN-ABL groups . Improvement in NYHA class was significantly greater in the + AVN-ABL group than in -AVN-ABL group ( -0.7 + /- 0.8 vs -0.4 + /- 0.8 , P = .04 ) . Survival estimates at 2 years were 96.0 % ( 95 % confidence interval [ CI ] 88.6%-100 % ) for + AVN-ABL group and 76.5 % ( 95 % CI 68.1%-85.8 % ) for-AVN-ABL group ( P = .008 ) . AVN ablation was independently associated with survival benefit from death ( hazard ratio [ HR ] 0.13 , 95 % CI 0.03 - 0.58 , P = .007 ) and from combined death , heart transplant , and left ventricular assist device ( HR 0.19 , 95 % CI 0.06 - 0.62 , P = .006 ) after CRT . CONCLUSION Among patients with atrial fibrillation and heart failure receiving CRT , AVN ablation for definitive biventricular pacing provides greater improvement in NYHA class and survival benefit . Larger-scale r and omized trials are needed to assess the clinical and survival outcomes of this therapy Background —Atrioventricular nodal radiofrequency ablation ( AVNA ) with permanent ventricular pacing can be used to control rate in patients with atrial fibrillation ( AF ) . However , long-term outcomes after AVNA are uncertain , especially in light of irreversible pacemaker dependence . Methods and Results —We examined 9122 consecutive patients with AF . The outcomes in 453 patients with AVNA ( 26 % of whom underwent an implantable cardiac defibrillator implant and 37 % underwent cardiac resynchronization therapy implant ) were compared with AF patients without AVNA after propensity score 1:1 matching . During follow-up in the propensity-matched cohort ( 2.41±3.23 years , median 1.23 , quartiles 0.33–3.12 ) , 100 patients died ( yearly rate of death 6.6 % ) . Mode of death was available in 86 % of patients , which was cardiovascular in 67 % of the patients ( related to heart failure in 38 % , sudden death in 5 % , and other cardiovascular reason in 24 % ) and noncardiovascular in 33 % . AVNA in patients with AF was associated with a lower risk of mortality ( odds ratio 0.47 , 95 % confidence interval , 0.29–0.77 ; P=0.003 ) , a lower risk of cardiovascular mortality ( odds ratio = 0.41 , 95 % confidence interval 0.23–0.73 ; P=0.003 ) , and nonsignificant lower risk of stroke and thromboembolic events ( odds ratio = 0.61 , 95 % confidence interval 0.36–1.06 ; P=0.08 ) . Conclusions —In sick AF patients with multiple comorbidities  , AVNA with permanent ventricular pacing for rate control seems safe during follow-up and may be associated with lower mortality 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 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 Objective : To compare the effects of cardiac resynchronisation therapy ( CRT ) in patients with heart failure ( HF ) in either atrial fibrillation ( AF ) or sinus rhythm ( SR ) . Design : Prospect i ve observational study . Patients : 295 consecutive patients with HF ( permanent AF in 66 , paroxysmal AF in 20 , SR in 209 ; New York Heart Association ( NYHA ) class III or IV ; left ventricular ejection fraction ( LVEF ) ⩽35 % , QRS ⩾120 ms ) . Interventions : All patients underwent CRT without atrioventricular junction ablation . Main outcome measures : The primary end point was the composite of cardiovascular death or unplanned hospitalisation for major cardiovascular events . Secondary end points included the composite of cardiovascular death or hospitalisation for worsening HF . Cardiovascular mortality , total mortality and changes in NYHA class , 6-minute walking distance , quality of life ( Minnesota Living with Heart Failure question naire ) and echocardiographic variables were also considered . Results : Over a follow-up period of up to 6.8 years , no differences emerged between patients in AF or SR in any of the mortality or morbidity end points . The AF and SR groups derived similar improvements in mean NYHA class ( −1.3 vs –1.2 ) , 6-minute walking distance ( 92.3 vs 78.4 m ) and quality of life scores ( −25.2 vs –18.7 ) ( all p<0.001 ) . In both the AF and the SR groups , reductions were seen in left ventricular end-systolic ( −25.9 vs –34.5 ml , both p<0.001 ) and end-diastolic ( −20.2 ml , p = 0.001 vs 26.2 ml , p<0.001 ) volumes and improvements in LVEF ( 4.69 % vs 7.86 % , both p<0.001 ) . Conclusions : Cardiac resynchronisation therapy leads to similar prognostic and symptomatic benefits in patients in AF and SR , even without atrioventricular junction ablation . Echocardiographic improvements are also comparable OBJECTIVES This study sought to compare catheter ablation with rate control for persistent atrial fibrillation ( AF ) in heart failure ( HF ) . BACKGROUND The optimal therapy for AF in HF is unclear . Drug-based rhythm control has not proved clinical ly beneficial . Catheter ablation improves cardiac function in patients with HF , but impact on physiological performance has not been formally evaluated in a r and omized trial . METHODS In a r and omized , open-label , blinded-endpoint clinical trial , adults with symptomatic HF , radionuclide left ventricular ejection fraction ( EF ) ≤35 % , and persistent AF were assigned to undergo catheter ablation or rate control . Primary outcome was 12-month change in peak oxygen consumption . Secondary endpoints were quality of life , B-type natriuretic peptide , 6-min walk distance , and EF . Results were analyzed by intention-to-treat . RESULTS Fifty-two patients ( age 63 ± 9 years , EF 24 ± 8 % ) were r and omized , 26 each to ablation and rate control . At 12 months , 88 % of ablation patients maintained sinus rhythm ( single-procedure success 68 % ) . Under rate control , rate criteria were achieved in 96 % . The primary endpoint , peak oxygen consumption , significantly increased in the ablation arm compared with rate control ( difference + 3.07 ml/kg/min , 95 % confidence interval : 0.56 to 5.59 , p = 0.018 ) . The change was not evident at 3 months ( + 0.79 ml/kg/min , 95 % confidence interval : -1.01 to 2.60 , p = 0.38 ) . Ablation improved Minnesota score ( p = 0.019 ) and B-type natriuretic peptide ( p = 0.045 ) and showed nonsignificant trends toward improved 6-min walk distance ( p = 0.095 ) and EF ( p = 0.055 ) . CONCLUSIONS This first r and omized trial of ablation versus rate control to focus on objective exercise performance in AF and HF shows significant benefit from ablation , a strategy that also improves symptoms and neurohormonal status . The effects develop over 12 months , consistent with progressive amelioration of the HF syndrome . ( A R and omised Trial to Assess Catheter Ablation Versus Rate Control in the Management of Persistent Atrial Fibrillation in Chronic Heart Failure ; NCT00878384 ) Atrial fibrillation ( AF ) represents the most common sustained cardiac arrhythmia in patients with heart failure ( HF ) . AF in HF patients is associated with worsening of symptoms and also results in a substantial increase in mortality . Although HF patients in sinus rhythm have a better outcome than patients with AF , several r and omized studies investigating pharmacological rhythm control versus rate control have shown no advantage of one strategy over the other in terms of patient outcomes . Catheter-based ablation therapy is a newer therapeutic option with a rapidly evolving and changing role in the management of this arrhythmia . In the present review , the authors discuss the epidemiology , pathophysiology and prognostic significance of AF in patients with HF . Exclusively addressed are studies investigating catheter-based ablation for rhythm-control and rate-control therapies in the management of AF in HF patients Background — Atrial fibrillation/flutter ( AF ) and heart failure often coexist ; however , the effect of cardiac resynchronization therapy ( CRT ) on the incidence of AF and on the outcome of patients with new-onset AF remains undefined . Methods and Results — In the CArdiac REsynchronisation in Heart Failure ( CARE-HF ) trial , 813 patients with moderate or severe heart failure were r and omly assigned to pharmacological therapy alone or with the addition of CRT . The incidence of AF was assessed by adverse event reporting and by ECGs during follow-up , and the impact of new-onset AF on the outcome and efficacy of CRT was evaluated . By the end of the study ( mean duration of follow-up 29.4 months ) , AF had been documented in 66 patients in the CRT group compared with 58 who received medical therapy only ( 16.1 % versus 14.4 % ; hazard ratio 1.05 ; 95 % confidence interval , 0.73 to 1.50 ; P=0.79 ) . There was no difference in the time until first onset of AF between groups . Mortality was higher in patients who developed AF , but AF was not a predictor in the multivariable model ( hazard ratio 1.17 ; 95 % confidence interval , 0.82 to 1.67 ; P=0.37 ) . In patients with new-onset AF , CRT significantly reduced the risk for all-cause mortality and all other predefined end points and improved ejection fraction and symptoms ( no interaction between AF and CRT ; all P>0.2 ) . Conclusions — Although CRT did not reduce the incidence of AF , CRT improved the outcome regardless of whether AF developed OBJECTIVES We evaluated the incidence and predictors of sudden death after  atrioventricular ( AV ) node ablation and pacemaker implantation .  BACKGROUND Sudden death may occur after radiofrequency catheter ablation of the AV node and pacemaker implantation in patients with atrial fibrillation ( AF ) . Whether it is related to the procedure or to pre-existing heart disease remains unclear . METHODS All patients who had radiofrequency catheter ablation of the AV node and pacemaker implantation for rate control of medically refractory AF were identified retrospectively and observed prospect ively . All patients with sudden death after ablation were identified . The relationship between the procedure and sudden death was defined on the basis of the time between the two as " likely , " " possibly " or " unlikely . " RESULTS Of 334 consecutive patients with AF who underwent AV node ablation  , nine had sudden death after the ablation . Four patients ( 1.2 % ) had sudden death likely related to the procedure : in 3 patients , arrest occurred within 48 h after the procedure ; in one patient , arrest occurred four days after the procedure . In three other patients ( 0.9 % ) , sudden death was possibly related to the procedure because the event occurred within three months afterward . The remaining two deaths were unrelated to the procedure . Diabetes , New York Heart Association functional class ( > or = II ) , preprocedure ventricular arrhythmia , mitral or aortic stenosis , aortic regurgitation and chronic obstructive pulmonary disease were independent predictors for sudden death . CONCLUSIONS Sudden death likely or possibly related to catheter ablation occurred in 7 of 334 patients ( 2.1 % ) . Risk of sudden death is highest within two days after the procedure ACCF : American College of Cardiology Foundation ACCP : American College of Chest Physicians ACS : acute coronary syndrome ACT : Atrial arrhythmia Conversion Trial ADONIS : American – Australian – African trial with DronedarONe In atrial fibrillation or flutter for the maintenance of Sinus rhythm AF : atrial fibrillation AHA : American Heart Association AND ROMEDA : ANtiarrhythmic trial with DROnedarone in Moderate-to-severe congestive heart failure Evaluating morbidity DecreAse APHRS : Asia Pacific Heart Rhythm Society aPTT : activated partial thromboplastin time ARB : angiotensin-receptor blocker ARISTOTLE : Apixaban for Reduction In STroke and Other ThromboemboLic Events in atrial fibrillation ATHENA : A placebo-controlled , double-blind , parallel arm Trial to assess the efficacy of dronedarone 400 mg b.i.d . for the prevention of cardiovascular Hospitalization or death from any cause in patiENts with Atrial fibrillation/atrial flutter ATRIA : AnTicoagulation and Risk factors In Atrial fibrillation AVERROES : Apixaban VErsus acetylsalicylic acid ( ASA ) to Reduce the Rate Of Embolic Stroke in atrial fibrillation patients who have failed or are unsuitable for vitamin K antagonist treatment AVRO : A prospect i ve , r and omized , double-blind , Active-controlled , superiority study of Vernakalant vs. amiodarone in Recent Onset atrial fibrillation b.i.d : bis in die ( twice daily ) b.p.m . : beats per minute CABANA : Catheter ABlation vs . ANtiarrhythmic drug therapy for Atrial fibrillation CABG : coronary artery bypass graft CAP : Continued Access to Protect AF CHA2DS2-VASc : Congestive heart failure or left ventricular dysfunction Hypertension , Age ≥75 ( doubled ) , Diabetes , Stroke (doubled)-Vascular disease , Age 65–74 , Sex category ( female ) CHADS2 : Congestive heart failure , Hypertension , Age ≥75 , Diabetes , Stroke ( doubled ) CI : confidence interval CRAFT : Controlled R and omized Atrial Fibrillation Trial CrCl : creatinine clearance DAFNE : Dronedarone Atrial FibrillatioN study after Electrical cardioversion DIONYSOS : R and omized Double blind trIal to evaluate efficacy and safety of drOnedarone ( 400 mg b.i.d . ) vs . amiodaroNe ( 600 mg q.d . for 28 daYS , then 200 mg qd thereafter ) for at least 6 mOnths for the maintenance of Sinus rhythm in patients with atrial fibrillation EAST : Early treatment of Atrial fibrillation for Stroke prevention Trial EHRA : European Heart Rhythm Association ECG : electrocardiogram EMA : European Medicines Agency ERATO : Efficacy and safety of dRonedArone for The cOntrol of ventricular rate during atrial fibrillation EURIDIS : EURopean trial In atrial fibrillation or flutter patients receiving Dronedarone for the maIntenance of Sinus rhythm FAST : atrial Fibrillation catheter Ablation vs . Surgical ablation Treatment FDA : Food and Drug Administration Flec-SL : Flecainide Short-Long trial HAS-BLED : Hypertension , Abnormal renal/liver function , Stroke , Bleeding history or predisposition , Labile INR , Elderly , Drugs/alcohol concomitantly HF-PEF : heart failure with preserved ejection fraction HF-REF : heart failure with reduced ejection fraction HR : hazard ratio HRS : Heart Rhythm Society ICH : intracranial haemorrhage INR : international normalized ratio i.v . : intravenous J-RHYTHM : Japanese RHYTHM management trial for atrial fibrillation LAA : left atrial appendage LoE : level of evidence LVEF : left ventricular ejection fraction MANTRA-PAF : Medical ANtiarrhythmic Treatment or Radiofrequency Ablation in Paroxysmal Atrial Fibrillation NICE : National Institute for Health and Clinical Excellence NOAC : novel oral anticoagulant NSAID : non-steroidal anti-inflammatory drug NYHA : New York Heart Association OAC : oral anticoagulant or oral anticoagulation o.d . : omni die ( every day ) PALLAS : Permanent Atrial fibriLLAtion outcome Study using dronedarone on top of st and ard therapy PCI : percutaneous coronary intervention PREVAIL : Prospect i ve R and omized EVAluation of the LAA closure device In patients with atrial fibrillation v s. Long-term warfarin therapy PROTECT AF : WATCHMAN LAA system for embolic PROTECTion in patients with Atrial Fibrillation PT : prothrombin time RAAFT : Radio frequency Ablation Atrial Fibrillation Trial RE-LY : R and omized Evaluation of Long-term anticoagulant therapY with dabigatran etexilate ROCKET-AF : Rivaroxaban Once daily oral direct factor Xa inhibition Compared with vitamin K antagonism for prevention of stroke and Embolism Trial in atrial fibrillation RRR : relative risk reduction TE : thromboembolism TIA : transient ischaemic attack t.i.d . : ter in die ( three times daily ) TOE : transoesophageal echocardiogram TTR : time in therapeutic range VKA : vitamin K antagonist Guidelines summarize and evaluate all currently available evidence on a particular issue with the aim of assisting physicians in selecting the best management strategy for an individual patient suffering from a given condition , taking into account the impact on 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 BACKGROUND Atrial fibrillation ( AF ) is the most common sustained cardiac arrhythmia imposing substantial morbidity and mortality . Catheter-based pulmonary vein isolation ( PVI ) using radiofrequency current ( RFC ) has become a st and ard treatment for drug-resistant and symptomatic paroxysmal AF ( PAF ) . In recent years , the cryoballoon-based technique is increasingly used as a promising alternative with a short learning curve . METHODS The FIRE AND ICE trial is a prospect i ve , r and omized , controlled , open , blinded outcome assessment , noninferiority trial comparing cryoballoon- , and RFC-based PVI .  Patients with drug-resistant PAF will be r and omized in a 1:1 matrix in multiple European centers . The primary hypothesis is that cryoballoon ablation is not inferior to RFC ablation using 3-dimensional mapping with respect to clinical efficacy . The primary endpoint is defined as the time to first documented clinical failure , including : ( 1 ) recurrence of AF ; ( 2 ) atrial flutter or atrial tachycardia ; ( 3 ) prescription of class I or III antiarrhythmic drugs ; or ( 4 ) re-ablation , whichever comes first , following a blanking period of 3 months after the index ablation procedure . The primary safety endpoint is a composite of death , stroke/transient ischemic attack , cardiac arrhythmias ( apart from AF recurrence ) causally related to the therapeutic intervention , and procedure-related serious adverse events . CONCLUSION The FIRE AND ICE trial compares 2 different technologies to perform catheter ablation of PAF with respect to efficacy and safety . It aims at providing objective data to guide selection and usage of ablation catheters in the treatment of AF AIMS In the setting of congestive heart failure ( CHF ) , atrial fibrillation ( AF ) ablation can improve clinical status and the left ventricular ejection fraction ( LVEF ) value . However , the impact of AF ablation on the implantable cardioverter defibrillator ( ICD ) indication has never been specifically addressed . METHODS AND RESULTS Study subject were six CHF ( mean age 61.1 + /- 6.9 years , mean LVEF 25.8 + /- 7.3 % ) patients refractory to conventional medical treatment with long-lasting AF unresponsive to external cardioversion . Five patients had an idiopathic dilated cardiomyopathy ( DCM ) and one had an ischaemic cardiomyopathy ( ICM ) . Their New York Heart Association ( NYHA ) class was III-IV . Two patients had renal insufficiency . No patient had left ventricular delay . All patients underwent AF ablation .  LVEF and NYHA class were dramatically improved in the five DCM patients . New York Heart Association class , but not the LVEF , was improved in the ICM patient . A redo ablative procedure was undertaken in four of five DCM patients and in the ICM patient due to arrhythmia recurrence . Left ventricular ejection fraction and NYHA were improved again in the DCM patients ( 56 + /- 4.4 % , I-II , respectively ) and led to ICD indication preclusion . The LVEF remained low in the ICM patient ( 30 % ) and led to ICD insertion . Sinus rhythm has been stable during the 18.1 + /- 5.7 months follow-up period . CONCLUSION  Atrial fibrillation ablation in CHF patients can improve both the clinical status of patients and their LVEF , especially among those affected by DCM . The LVEF improvement has the potential to preclude the indication for a primary prevention ICD insertion 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 ) OBJECTIVES The purpose of this study was to determine the long-term clinical outcomes of catheter ablation of atrial fibrillation ( AF ) substrate for high-risk patients with AF . BACKGROUND The benefits of catheter ablation for high-risk AF patients with respect to mortality and stroke reductions remain unclear . METHODS We performed AF substrate ablation guided by complex fractionated atrial electrogram ( CFAE ) mapping in 674 high-risk AF patients . The clinical end points were sinus rhythm ( SR ) , death , stroke , or bleeding .  Of these 674 patients , 635 were available for follow-up and made up the study cohort . The patients were relatively old ( mean age 67 + /- 12 years ) and 129 had an ejection fraction ( EF ) < 40 % . RESULTS After the mean follow-up period of 836 + /- 605 days , 517 were in SR ( 81.4 % ) . There were 15 deaths among the patients who stayed in SR compared with 14 deaths among those who remained in AF ( 5-year survival rate , 92 % vs. 64 % , respectively ; p < 0.0001 ) . SR was the most important independent favorable parameter for survival ( hazard ratio 0.14 , 95 % confidence interval 0.06 to 0.36 , p < 0.0001 ) , whereas old age was unfavorable . Warfarin therapy was discontinued in 434 of the 517 patients in SR post-ablation ( 84 % ) whose annual stroke rate was only 0.4 % compared with 2 % in those with continuing warfarin treatment ( p = 0.004 ) . CONCLUSIONS CFAE-targeted ablation of AF is effective in maintaining SR in selected high-risk AF patients and might allow patients to stop warfarin therapy . SR after AF ablation is a marker of relatively low mortality and stroke risk . Our findings support conducting further r and omized studies to determine whether AF ablation is associated with mortality and /or stroke reduction BACKGROUND Pulmonary-vein isolation is increasingly being used to treat atrial fibrillation in patients with heart failure . METHODS In this prospect i ve , multicenter clinical trial , we r and omly assigned patients with symptomatic , drug-resistant atrial fibrillation , an ejection fraction of 40 % or less , and New York Heart Association class II or III heart failure to undergo either pulmonary-vein isolation or atrioventricular-node ablation with biventricular pacing .  All patients completed the Minnesota Living with Heart Failure question naire ( scores range from 0 to 105 , with a higher score indicating a worse quality of life ) and underwent echocardiography and a 6-minute walk test ( the composite primary end point ) . Over a 6-month period , patients were monitored for both symptomatic and asymptomatic episodes of atrial fibrillation . RESULTS In all , 41 patients underwent pulmonary-vein isolation  , and 40 underwent atrioventricular-node ablation with biventricular pacing ; none were lost to follow-up at 6 months . The composite primary end point favored the group that underwent pulmonary-vein isolation , with an improved question naire score at 6 months ( 60 , vs. 82 in the group that underwent atrioventricular-node ablation with biventricular pacing ; P<0.001 ) , a longer 6-minute-walk distance ( 340 m vs. 297 m , P<0.001 ) , and a higher ejection fraction ( 35 % vs. 28 % , P<0.001 ) . In the group that underwent pulmonary-vein isolation , 88 % of patients receiving antiarrhythmic drugs and 71 % of those not receiving such drugs were free of atrial fibrillation at 6 months . In the group that underwent pulmonary-vein isolation , pulmonary-vein stenosis developed in two patients , pericardial effusion in one , and pulmonary edema in another ; in the group that underwent atrioventricular-node ablation with biventricular pacing , lead dislodgment was found in one patient and pneumothorax in another . CONCLUSIONS Pulmonary-vein isolation was superior to atrioventricular-node ablation with biventricular pacing in patients with heart failure who had drug-refractory atrial fibrillation . ( Clinical Trials.gov number , NCT00599976 .
Surrogate outcomes showed a similar benefit favoring CA .
Conclusion and Relevance Catheter ablation for AF in HFrEF is associated with improvement in patient-centered outcomes and surrogate outcomes when compared to st and ard medical therapy with or without device therapy
Background Atrial fibrillation ( AF ) among patients with heart failure with reduced ejection fraction ( HFrEF ) is associated with adverse clinical outcomes .
Our primary aim was to evaluate patient-centered outcomes and surrogate outcomes following catheter ablation ( CA ) of AF among patients with HFrEF compared to st and ard medical therapy with or without device therapy ( atrioventricular node ablation and cardiac resynchronization therapy ) .