A Randomized Trial to Assess Catheter Ablation Versus Rate Control in the Management of Persistent Atrial Fibrillation in Heart Failure (ARC-HF)

Study Questions:

Does radiofrequency catheter ablation (RFCA) of persistent atrial fibrillation (AF) improve cardiovascular function compared to rate control in patients with heart failure (HF)?

Methods:

Fifty-two patients (mean age 63 years) with persistent AF, HF, and an ejection fraction (EF) ≤35% (mean EF 24%) were randomly assigned to RFCA (n = 26) or pharmacological rate control (n = 26). RFCA consisted of pulmonary vein isolation, linear ablation at the mitral isthmus and left atrial roof, and ablation of complex atrial electrograms. Rate control targets were ≤80 bpm at rest and ≤110 bpm after a 6-minute walk. Peak oxygen consumption (VO2) was measured at baseline and 3, 6, and 12 months of follow-up, and was the primary endpoint.

Results:

The single- and multi-procedure success rates in the ablation group were 72% and 92%, respectively. Peak VO2 was significantly higher (+3.07 ml/kg/min) at 12 months in the ablation group. B-type natriuretic peptide at 12 months fell by a significantly greater degree in the ablation group (-124 pg/ml) than in the rate-control group (-18 pg/ml).

Conclusions:

The authors concluded that exercise performance and neurohormonal status in patients with persistent AF and HF improve to a greater degree after RFCA than with rate control.

Perspective:

Several randomized studies have demonstrated no advantages of a drug-based rhythm-control strategy over a rate-control strategy in patients with AF, including those with HF. The adverse effects and limited efficacy of antiarrhythmic drugs could have contributed to the negative results. This small, but important study demonstrates that sinus rhythm achieved by RFCA indeed does have objective advantages over rate control in patients with AF and HF.

Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Heart Failure and Cardiac Biomarkers

Keywords: Follow-Up Studies, Disease Management, Heart Diseases, Rest, Natriuretic Peptides, Oxygen Consumption, Biological Markers, Heart Failure, Atrial Natriuretic Factor, Catheter Ablation


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