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

Nov 05, 2012
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Author/Summarized by Author:
Anthony A. Bavry, MD, MPH, FACC
Summary Reviewer:
Deepak L. Bhatt, MD, MPH, MBA, FACC
Trial Sponsor:
NIHR Cardiovascular Biomedical Research Unit
Date Presented:
01/01/2012
Date Updated:
11/05/2012
Original Posted Date:
11/05/2012
References

Description:

The goal of the trial was to evaluate a strategy of rhythm control with catheter ablation compared with rate control with medications among patients with persistent atrial fibrillation and chronic heart failure.

Hypothesis:

Rhythm control will improve cardiovascular performance, symptoms, and neuroendocrine status.

Study Design

  • Randomized
  • Parallel

Patient Populations:

  • Patients 18-80 years of age with persistent atrial fibrillation and left ventricular ejection fraction ≤35% with NYHA class II-IV heart failure on optimal medical therapy

    Number of screened applicants: 101
    Number of enrollees: 52
    Duration of follow-up: 12 months
    Mean patient age: 64 years
    Percentage female: 19%
    Ejection fraction: 22%
    New York Heart Association class: II-54%, III-46%

Exclusions:

  • Cardiac resynchronization therapy or implantable cardioverter-defibrillator (ICD) within 6 months
  • Atrioventricular node ablation within 3 months
  • Persistent left atrial thrombus
  • Active malignancy
  • Stroke within 6 months
  • Reversible cause of atrial fibrillation
  • Reversible cause of heart failure
  • Myocardial infarction, percutaneous coronary intervention, or coronary artery bypass grafting within 3 months
  • Prior atrial fibrillation ablation
  • Heart transplant or on the wait list for a heart transplant
  • Neuromuscular disease
  • Renal insufficiency
  • Contraindication to anesthesia or anticoagulation

Primary Endpoints:

  • Peak oxygen consumption (VO2) during cardiopulmonary exercise treadmill test

Secondary Endpoints:

  • Quality of life, 6-minute walk distance, BNP value, ejection fraction, and freedom from atrial fibrillation/flutter

Drug/Procedures Used:

Patients with persistent atrial fibrillation and chronic heart failure were randomized to a strategy of rhythm control with catheter ablation (n = 26) versus rate control with medications (n = 26).

Patients in the rhythm control group could receive a total of three procedures. Target heart rate in the rate control group was <80 bpm at rest or <110 bpm during exercise.

Principal Findings:

Overall, 52 patients were randomized. The mean age was 64 years, 19% were women, etiology of heart failure was nonischemic in 62%, and mean left ventricular ejection fraction was 22%.

In the catheter ablation group, the mean procedure time was 333 minutes, and there was one case of tamponade. Five patients underwent a second procedure; therefore, the multi-procedural success rate was 92%.

In the rate control group, two were in sinus rhythm at 12 months. Of the patients that remained in atrial fibrillation, 96% were rate controlled at 12 months.

The primary outcome, peak oxygen consumption at 12 weeks, was increased 3.1 ml/kg/min in the catheter ablation group versus the rate control group (p = 0.018).

Quality of life and B-type natriuretic peptide (BNP) values were improved in the catheter ablation group (p < 0.05 for each). Left atrial size was also smaller in the catheter ablation group versus the rate control group (p = 0.001).

Interpretation:

Among patients with persistent atrial fibrillation and chronic heart failure, rhythm control by catheter ablation was successful at improving cardiopulmonary exercise performance (measured by peak oxygen consumption). The catheter ablation group was also associated with a smaller left atrial size, improved quality of life, and lower BNP values. Future studies in this patient population are needed to assess the effect of catheter ablation on clinical outcomes.

References:

Presented by Dr. David Jones at the American Heart Association Scientific Sessions, Los Angeles, CA, November 5, 2012.

Keywords: Rest, Heart Atria, Oxygen Consumption, Quality of Life, Exercise, Heart Failure, Stroke Volume, Heart Rate, Catheter Ablation, Natriuretic Peptide, Brain


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