Ablation for Atrial Fibrillation in Heart Failure | Journal Scan

Study Questions:

Is a rhythm-control strategy superior to rate control in patients with atrial fibrillation (AF) and congestive heart failure (CHF)?

Methods:

The authors performed a meta-analysis of studies that randomized patients with AF and CHF (left ventricular ejection fraction [LVEF] <50%) to a sinus-rhythm strategy via catheter ablation or rate control. The ablation protocol consisted of at least pulmonary vein (PV) isolation. Ablation targets outside the PVs varied between studies. Rate control could be achieved with pharmacotherapy or atrioventricular (AV) junction ablation.

Results:

Four studies (n = 224 patients, 83% persistent AF [mean duration, 1 year], mean EF, 26%) met the inclusion criteria. The proportion of patients requiring repeat ablation procedures varied from 20-54%. Freedom from AF was achieved in 50-88% of patients. As compared to rate control, catheter ablation was associated with an 8.5% increase in EF, improvement in quality-of-life measures, 6-minute walk distance, and peak oxygen consumption. Major event rates in the ablation and rate control arms were similar (7% vs. 5%, p = 0.64).

Conclusions:

The authors concluded that a sinus-rhythm strategy with catheter ablation is superior to a rate-control strategy in patients with AF and CHF.

Perspective:

A large randomized study using antiarrhythmic medications in patients with AF and CHF failed to show improved outcomes in patients randomized to a sinus-rhythm strategy. A prior study also showed that patients undergoing atrial ablation fare better than those undergoing AV junction ablation with biventricular pacing. This meta-analysis confirms the superiority of catheter ablation in such patients, and also indirectly confirms the limitations of antiarrhythmic medications (e.g., suboptimal efficacy, and the possibly that their potential benefits may be negated by their deleterious effects). Patients with AF and concomitant CHF may not be referred for catheter ablation owing to the misconception that they are poor candidates for such procedures. However, these patients are more likely to gain not only in terms of symptoms, but also important endpoints such as LV performance. Future studies should focus on streamlining the ablation approach, minimizing the number of repeat procedures, and confirming that the results are maintained over long-term follow-up.

Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure

Keywords: Ablation Techniques, Anti-Arrhythmia Agents, Arrhythmias, Cardiac, Atrial Fibrillation, Cardiac Resynchronization Therapy, Catheter Ablation, Heart Failure, Oxygen Consumption, Pulmonary Veins, Quality of Life, Stroke Volume, Ventricular Function, Left


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