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.