title: Electrical Remodeling of the Atria in Congestive Heart Failure: Electrophysiological and Electroanatomic Mapping in Humans Reverse Remodeling of the Left Cardiac Chambers After Catheter Ablation After 1 Year in a Series of Patients With Isolated Atrial Fibrillation Catheter ablation in selected patients with depressed left ventricular ejection fraction and persistent atrial fibrillation unresponsive to current cardioversion. Ablation vs medical therapy in the setting of symptomatic atrial fibrillation and left ventricular dysfunction. Pulmonary vein isolation for the treatment of atrial fibrillation in patients with impaired systolic function. Radiofrequency ablation for persistent atrial fibrillation in patients with advanced heart failure and severe left ventricular systolic dysfunction: a randomised controlled trial 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. A Randomized Controlled Trial of Catheter Ablation Versus Medical Treatment of Atrial Fibrillation in Heart Failure (The CAMTAF Trial) Catheter ablation for atrial fibrillation results in greater improvement in cardiac function in patients with low versus normal left ventricular ejection fraction Catheter ablation of paroxysmal atrial fibrillation improves cardiac function: a prospective study on the impact of atrial fibrillation ablation on left ventricular function assessed by magnetic resonance imaging. Left ventricular systolic dysfunction by itself does not influence outcome of atrial fibrillation ablation Impact of Stepwise Ablation on the Biatrial Substrate in Patients With Persistent Atrial Fibrillation and Heart Failure Pulmonary-vein isolation for atrial fibrillation in patients with heart failure. Pulmonary vein vestibule ablation for the control of atrial fibrillation in patients with impaired left ventricular function. Clinical outcomes of catheter substrate ablation for high-risk patients with atrial fibrillation. A randomized trial to assess catheter ablation versus rate control in the management of persistent atrial fibrillation in heart failure. Catheter ablation for atrial fibrillation in congestive heart failure.
abstract: Background —Atrial  fibrillation ( AF ) frequently complicates congestive heart failure ( CHF ) . However , the electrophysiological substrate for AF in humans with CHF remains unknown . We evaluated the electrophysiological and electroanatomic characteristics of the atria in patients with CHF . Methods and Results —Twenty-one patients ( aged 53.7±13.6 years ) with symptomatic CHF ( left ventricular ejection fraction 25.5±6.0 % ) and 21 age-matched controls were studied . The following were evaluated : effective refractory periods ( ERPs ) from the high and low lateral right atrium ( LRA ) , high septal right atrium , and distal coronary sinus ( CS ) ; conduction time along the CS and LRA ; corrected sinus node recovery times ; P-wave duration ; and conduction at the crista terminalis . In a subset , electroanatomic mapping was performed to determine atrial activation , regional conduction velocity , double potentials , fractionated electrograms , regional voltage , and areas of electrical silence .  Patients with CHF demonstrated an increase in atrial ERP with no change in the heterogeneity of refractoriness , an increase of atrial conduction time along the LRA and the CS , prolongation of the P-wave duration and corrected sinus node recovery times , and greater number and duration of double potentials along the crista terminalis . Electroanatomic mapping demonstrated regional conduction slowing with a greater number of electrograms with fractionation or double potentials , associated with areas of low voltage and electrical silence ( scar ) . Patients with CHF demonstrated an increased propensity for AF with single extrastimuli , and induced AF was more often sustained . Conclusions —Atrial remodeling due to CHF is characterized by structural changes , abnormalities of conduction , sinus node dysfunction , and increased refractoriness . These abnormalities may be responsible in part for the increased propensity for AF in CHF Background — Isolated atrial fibrillation ( AF ) is associated with mild enlargement of the left atrium ( LA ) and left ventricular ( LV ) diastolic dysfunction . The impact of ablation of isolated AF on left chamber size and function is unclear , and whether diastolic dysfunction is the cause or the consequence of AF remains unknown . The objective of this prospect i ve study was to evaluate the impact of sinus rhythm restoration by catheter ablation on LV diastolic dysfunction , LA morphology , and mechanical function . Methods and Results — Forty-eight patients with isolated AF were studied by serial echocardiographic studies at baseline and at 1- , 3- , 6- , 9- , and 12-month intervals after radiofrequency ablation .  LA dimensions and mechanical function and LV systolic and diastolic functions were evaluated at each time interval . Diastolic function was assessed with conventional Doppler parameters and new indexes such as tissue Doppler imaging , mitral flow propagation velocity , and combined criteria . LV diastolic dysfunction was present in paroxysmal and chronic AF patients with a reduction of tissue Doppler imaging lateral early diastolic peak velocity in 37 % ( P<0.001 ) and 48 % ( P<0.01 ) , respectively , compared with healthy control subjects . At the end of the follow-up , LA area decreased significantly by 18 % ( P<0.001 ) in paroxysmal and 23 % ( P<0.05 ) in chronic AF patients . Diastolic function improved significantly with an increase in lateral early diastolic peak velocity of 29 % ( P<0.001 ) in paroxysmal AF and 46 % ( P<0.05 ) in chronic AF patients . A significant increase in LV ejection fraction was also noted for both groups : 7.7 % and 18.8 % , respectively . Conclusions — This study demonstrates reverse morphological remodeling of the LA and improvement of LV diastolic and systolic functions after restoration of sinus rhythm by ablation for isolated AF . Because patients with isolated AF have none of the traditional causes of LV diastolic dysfunction , our findings suggest that AF may be partly the cause rather than the consequence of diastolic dysfunction AIMS In congestive heart failure ( CHF ) patients with persistent atrial fibrillation ( AF ) , direct current cardioversion ( DCC ) may reveal participation of tachycardiamediated process to left ventricular ( LV ) dysfunction by restoring sinus rhythm ( SR ) . However , if DCC fails to restore SR , patients ' management remains challenging . The aim of the study was to assess the AF catheter ablation benefit in a selected group of CHF patients with LV ejection fraction ( LVEF ) < 40 % and persistent AF unresponsive to DCC , in whom a tachycardia-mediated process is thought to be predominant . METHODS AND RESULTS Between January 2008 and September 2011 , among 129 CHF patients with persistent AF referred to our institution , 34 ( 63.8 ± 9-year old , 24 men ) presented AF refractory to DCC with an estimated high likelihood of tachycardia-mediated LV dysfunction according to a specific set of criteria . These 34 patients underwent stepwise AF ablation and were closely followed up . After a mean 1.9 AF ablation procedures per patient and 17.6 ± 7 months after the last procedure , all patients were in SR . The New York Heart Association class improved from 2.8 ± 0.3 to 1 ± 0.2 ( P < 0.001 ) and the LVEF increased from 30.4 ± 6 to 54.6 ± 6 % ( P < 0.0001 ) after 3 - 6 months of SR , with a persistent benefit as long as the SR was maintained . CONCLUSION Atrial fibrillation catheter ablation in selected CHF patients with persistent AF refractory to DCC and without any other evidence for secondary LV dysfunction leads to a substantial LVEF improvement in the majority of them . However , redo procedures are frequent in order to achieve mid-term SR maintenance 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 OBJECTIVES We aim ed to determine the safety and efficacy of pulmonary vein isolation ( PVI ) in atrial fibrillation ( AF ) patients with impaired left ventricular ( LV ) systolic function . BACKGROUND To date , PVI has been performed primarily in patients with normal LV function . Yet , many AF patients have impaired LV systolic function . The outcomes of PVI in patients with impaired LV systolic function are unknown . METHODS We included 377 consecutive patients undergoing PVI between December 2000 and January 2003 . Ninety-four patients had impaired LV function ( ejection fraction [ EF ] < 40 % ) , and they comprised the study group . The control group was the remaining 283 patients who had a normal EF . End points included AF recurrence and changes in EF and quality of life ( QoL ) . RESULTS Mean EF was 36 % in our study group , compared with 54 % in controls . After initial PVI , 73 % of patients with impaired EF and 87 % of patients with normal EF were free of AF recurrence at 14 + /- 6 months ( p = 0.03 ) . In the study group , there was a nonsignificant increase in EF of 4.6 % and significant improvement in QoL. Complication rates were low and included a 1 % risk of pulmonary vein stenosis . CONCLUSIONS Although the AF recurrence rate after initial PVI in impaired EF patients was higher than in normal EF subjects , nearly three-fourths of patients with impaired EF remained AF-free . Although our sample size was nonr and omized , our results suggest PVI may be a feasible therapeutic option in AF patients with impaired EF . R and omized studies with more patients and longer follow-up are warranted Objective To determine whether or not radiofrequency ablation ( RFA ) for persistent atrial fibrillation in patients with advanced heart failure leads to improvements in cardiac function . Setting Patients were recruited from heart failure outpatient clinics in Scotl and . Design and intervention Patients with advanced heart failure and severe left ventricular dysfunction were r and omised to RFA ( rhythm control ) or  continued medical treatment  ( rate control ) . Patients were followed up for a minimum of 6 months . Main outcome measure Change in left ventricular ejection fraction ( LVEF ) measured by cardiovascular MRI . Results 22 patients were r and omised to RFA and 19 to medical treatment . In the RFA group , 50 % of patients were in sinus rhythm at the end of the study ( compared with none in the medical treatment group ) . The increase in cardiovascular magnetic resonance ( CMR ) LVEF in the RFA group was 4.5±11.1 % compared with 2.8±6.7 % in the medical treatment group ( p=0.6 ) . The RFA group had a greater increase in radionuclide LVEF ( a prespecified secondary end point ) than patients in the medical treatment group ( + 8.2±12.0 % vs + 1.4±5.9 % ; p=0.032 ) . RFA did not improve N-terminal pro-B-type natriuretic peptide , 6 min walk distance or quality of life . The rate of serious complications related to RFA was 15 % . Conclusions RFA result ed in long-term restoration of sinus rhythm in only 50 % of patients . RFA did not improve CMR LVEF compared with a strategy of rate control . RFA did improve radionuclide LVEF but did not improve other secondary outcomes and was associated with a significant rate of serious complications . Clinical trials registration number NCT00292162 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 —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 : 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 AIMS Beneficial effects of atrial fibrillation ( AF ) ablation have been demonstrated in patients with congestive heart failure ( CHF ) and significantly impaired left ventricular ejection fraction ( LVEF ) . However , the impact of pulmonary vein isolation ( PVI ) on cardiac function in patients with paroxysmal AF and impaired LVEF remains under discussion . This study aim ed to evaluate the impact of PVI for paroxysmal AF on cardiac function in patients with impaired LVEF using cardiac magnetic resonance imaging ( CMRI ) . METHODS AND RESULTS A total number of 70 patients with paroxysmal AF and episodes < or = 24 h were  scanned on a 1.5-T-CMRI before and 6 months after PVI during sinus rhythm . End-diastolic volume , end-systolic volume , and LVEF were determined by epicardial and endocardial measurements . Patients were categorized into two groups regarding cardiac function as assessed by CMRI : group 1 patients ( n = 18 ) with an LVEF < 50 % and patients with an LVEF > 50 % ( group 2 , n = 52 ) . Group 1 patients demonstrated a significant lower success rate than patients of group 2 after a follow-up of 152 + /- 40 days ( 50 vs. 73 % , P < 0.05 ) . Cardiac magnetic resonance imaging in group 1 patients demonstrated a significant improvement in cardiac function after AF ablation ( 41 + /- 6 vs. 51 + /- 12 % , P = 0.004 ) , whereas group 2 patients did not show significant differences ( 60 + /- 6 vs. 59 + /- 9 % , P = 0.22 ) after a 6 months follow-up . CONCLUSION Pulmonary vein isolation improves cardiac function in patients with paroxysmal AF and impaired LVEF . These data suggest that an impaired LV function can be partially attributed to AF with short-lasting paroxysms Aims The objective of the study was to analyse the influence of left ventricular ( LV ) ejection fraction ( EF ) on the outcomes of  atrial fibrillation ( AF ) ablation after a first procedure . Pre-procedural predictors of recurrences after AF ablation can be useful for patient information and selection of c and i date s. The independent influence of LV systolic dysfunction on recurrence rate has not been studied . Methods and results A case – control study ( 1:1 ) was conducted with a total of 72 patients : 36 cases ( depressed LVEF ) and 36 controls ( normal LVEF ) . Patients were matched by left atrial diameter ( LAD ) , the presence of arterial hypertension , and other variables that might influence the results ( age , gender and paroxysmal vs. persistent AF ) . There were no statistical differences in the variables used to perform the matching . Patients with depressed LVEF had higher LV end diastolic diameter ( 55.6 ± 6.2 vs. 52.4 ± 5.5 , P = 0.03 ) , higher LV end systolic diameter ( 40.3 ± 6.9 vs. 32.6 ± 4.3 , P < 0.001 ) , lower LVEF ( 41.4 ± 8.0 vs. 63.1 ± 5.5 , P < 0.001 ) and were more likely to have structural heart disease . After a mean follow-up of 16 ± 13 months , survival analysis for AF recurrences showed no differences between patients with depressed vs. normal LVEF ( 50.0 vs. 55.6 % , log rank = 0.82 ) . Cox regression analysis revealed LAD to be the only variable correlated to recurrence [ OR 1.11 ( 1.01–1.22 ) , P = 0.03 ] . Analysis at 6 months showed a significant increase in LVEF ( 43.23 ± 7.61 to 51.12 ± 13.53 % , P = 0.01 ) for the case group . Conclusion LV systolic dysfunction by itself is not a predictor of outcome after AF ablation . LAD independently correlates with outcome in patients with low or normal LVEF Background —Ablation of persistent atrial fibrillation can be challenging , often involving not only pulmonary vein isolation ( PVI ) but also additional linear lesions and ablation of complex fractionated electrograms ( CFE ) . We examined the impact of stepwise ablation on a human model of advanced atrial substrate of persistent atrial fibrillation in heart failure . Methods and Results —In 30 patients with persistent atrial fibrillation and left ventricular ejection fraction ⩽35 % , high-density CFE maps were recorded biatrially at baseline , in the left atrium ( LA ) after PVI and linear lesions ( roof and mitral isthmus ) , and biatrially after LA CFE ablation . Surface area of CFE ( mean cycle length ⩽120 ms ) remote to PVI and linear lesions , defined as CFE area , was reduced after PVI ( 18.3±12.03 to 10.2±7.1 cm2 ; P<0.001 ) and again after linear lesions ( 7.7±6.5 cm2 ; P=0.006 ) . Complete mitral isthmus block predicted greater CFE reduction ( P=0.02 ) . Right atrial CFE area was reduced by LA ablation , from 25.9±14.1 to 12.9±11.8 cm2 ( P<0.001 ) . Estimated 1-year arrhythmia-free survival was 72 % after a single procedure . Incomplete linear lesion block was an independent predictor of arrhythmia recurrence ( hazard ratio , 4.69 ; 95 % confidence interval , 1.05–21.06 ; P=0.04 ) . Conclusions —Remote LA CFE area was progressively reduced following PVI and linear lesions , and LA ablation reduced right atrial CFE area . Reduction of CFE area at sites remote from ablation would suggest either regression of the advanced atrial substrate or that these CFE were functional phenomena . Nevertheless , in an advanced atrial fibrillation substrate , linear lesions after PVI diminished the target area for CFE ablation , and complete lesions result ed in a favorable clinical outcome 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 . INTRODUCTION Congestive heart failure ( CHF ) and atrial fibrillation ( AF ) are frequently linked , and when associated produce additive deleterious effects . In this prospect i ve study , the effects of catheter ablation for AF  in patients with impaired left ventricular ( LV ) function are presented . METHODS Baseline data and clinical outcome have been prospect ively collected in 105 consecutive patients who underwent pulmonary vein ablation for the control of AF .  We evaluated 40 patients affected by LV dysfunction with ejection fraction (EF)<40 % and compared them to the remaining 65 patients with normal ventricular function in terms of changes in LV function , maintenance of sinus rhythm , and quality of life during follow-up . RESULTS After a mean follow-up of 14+/-2 months , 87 % of patients with impaired LV function and 92 % of patients with normal ventricular function were in sinus rhythm , with or without antiarrhythmic therapy ( P = NS ) . A significant improvement in LVEF and fractional shortening was documented in patients with CHF ( 33+/-2 % vs 47+/-3 % , and 19+/-4 % vs 30+/-3 % , P<0.01 for both comparisons ) . Evaluation of exercise capacity and quality of life documented better improvements in patients with CHF compared to patients without CHF . CONCLUSIONS Catheter ablation in patients with LV dysfunction is feasible , not associated with higher procedural complications , and provides a significant improvement in LV performance , symptoms , and quality of life during follow-up 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 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 ) BACKGROUND Congestive heart failure and atrial fibrillation often coexist , and each adversely affects the other with respect to management and prognosis . We prospect ively evaluated the effect of catheter ablation for atrial fibrillation on left ventricular function in patients with heart failure . METHODS We studied 58 consecutive patients with congestive heart failure and a left ventricular ejection fraction of less than 45 percent who were undergoing catheter ablation for atrial fibrillation .  We selected as controls 58 patients without congestive heart failure who were undergoing ablation for atrial fibrillation , matched according to age , sex , and classification of atrial fibrillation . We evaluated the patients ' left ventricular function and dimensions , symptom score , exercise capacity , and quality of life at baseline and at months 1 , 3 , 6 , and 12 . RESULTS After a mean ( + /-SD ) of 12+/-7 months , 78 percent of the patients with congestive heart failure and 84 percent of the controls remained in sinus rhythm ( P=0.34 ) ( 69 percent and 71 percent , respectively , were in sinus rhythm without the administration of antiarrhythmic drugs ) . The patients with congestive heart failure had significant improvement in left ventricular function ( increases in the ejection fraction and fractional shortening of 21+/-13 percent and 11+/-7 percent , respectively ; P<0.001 for both comparisons ) , left ventricular dimensions ( decreases in the diastolic and systolic diameters of 6+/-6 mm and 8+/-7 mm , respectively ; P=0.03 and P<0.001 , respectively ) , exercise capacity , symptoms , and quality of life . The ejection fraction improved significantly not only in patients without concurrent structural heart disease ( 24+/-10 percent , P<0.001 ) and those with inadequate rate control before ablation ( 23+/-10 percent , P<0.001 ) , but also in those with coexisting heart disease ( 16+/-14 percent , P<0.001 ) and adequate rate control before ablation ( 17+/-15 percent , P<0.001 ) . CONCLUSIONS Restoration and maintenance of sinus rhythm by catheter ablation without the use of drugs in patients with congestive heart failure and atrial fibrillation significantly improve cardiac function , symptoms , exercise capacity , and quality of life
target: Catheter ablation may be an effective therapy in AF patients with left ventricular systolic impairment , and can be associated with improvements in left ventricular function , quality of life , exercise capacity , and modest rates of serious adverse events
background: INTRODUCTION Catheter ablation of atrial fibrillation ( AF ) is an established rhythm control strategy ; however , the impact of co-existing LV systolic dysfunction ( LVSD ) on ablation success is less well understood .
  This systematic review compiles the outcomes of catheter ablation of atrial fibrillation in patients with LVSD .