title: Ablation vs medical therapy in the setting of symptomatic atrial fibrillation and left ventricular dysfunction. Atrial fibrillation and heart failure in cardiology practice: reciprocal impact and combined management from the perspective of atrial fibrillation: results of the Euro Heart Survey on atrial fibrillation. 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 CONSORT 2010 Statement: Updated Guidelines for Reporting Parallel Group Randomized Trials 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 Catheter ablation versus standard conventional treatment in patients with left ventricular dysfunction and atrial fibrillation (CASTLE-AF) - study design. Complications of atrial fibrillation ablation in a high-volume center in 1,000 procedures: still cause for concern? 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. Catheter ablation for atrial fibrillation in congestive heart failure. The risk of thromboembolism and need for oral anticoagulation after successful atrial fibrillation ablation.
abstract: 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 Our aim was to identify shortcomings in the management of patients with both atrial fibrillation ( AF ) and heart failure ( HF ) . BACKGROUND AF and HF often coincide in cardiology practice , and they are known to worsen each other 's prognosis , but little is known about the quality of care of this combination . METHODS In the observational Euro Heart Survey on AF , 5,333 AF patients were enrolled in 182 centers across 35 European Society of Cardiology member countries in 2003 and 2004 . A follow-up survey was performed after 1 year . RESULTS At baseline , 1,816 patients ( 34 % ) had HF .  Recommended therapy for HF with left ventricular systolic dysfunction ( LVSD ) with a beta-blocker and either an angiotensin-converting enzyme inhibitor ( ACEI ) or angiotensin II receptor blocker was prescribed in 40 % of HF patients , while 29 % received the recommended drug therapy for both LVSD-HF and AF , consisting of the combination of a beta-blocker , either ACEI or angiotensin II receptor blocker , and oral anticoagulation .  Rate control was insufficient with 40 % of all HF patients with permanent AF having a heart rate < or = 80 beats/min . In the total cohort , HF patients had a higher risk for mortality ( 9.5 % vs. 3.3 % ; p < 0.001 ) , ( progression of ) HF ( 24.8 % vs. 5.0 % ; p < 0.001 ) , and AF progression ( 35 % vs. 19 % ; p < 0.001 ) during 1-year follow-up . Of all recommended drugs for AF and LVSD-HF , only ACEI prescription was associated with improved survival during 1-year follow-up ( odds ratio : 0.51 [ 95 % confidence interval : 0.31 to 0.85 ] ; p = 0.011 ) . CONCLUSIONS The prescription rate of guideline -recommended drug therapy for AF and LVSD-HF is low . R and omized controlled trials targeting this highly prevalent subgroup with AF and HF are warranted 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 The CONSORT ( Consoli date d St and ards of Reporting Trials ) statement is used worldwide to improve the reporting of r and omized , controlled trials . Schulz and colleagues describe the latest version , CONSORT 2010 , which up date s the reporting guideline based on new method ological evidence and accumulating experience . 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 Electrical isolation of the pulmonary veins by catheter ablation is an emerging treatment modality for the treatment of atrial fibrillation ( AF ) and is increasingly used in patients with heart failure . METHODS The catheter ablation versus st and ard conventional treatment in patients with left ventricular dysfunction and atrial fibrillation trial ( CASTLE-AF ) is a r and omized evaluation of ablative treatment of atrial fibrillation in patients with left ventricular dysfunction . The primary endpoint is the composite of all-cause mortality or worsening of heart failure requiring unplanned hospitalization using a time to first event analysis . Secondary endpoints are all-cause mortality , cardiovascular mortality , cerebrovascular accidents , worsening of heart failure requiring unplanned hospitalization , unplanned hospitalization due to cardiovascular reason , all-cause hospitalization , quality of life , number of therapies ( shock and antitachycardia pacing ) delivered by the implantable cardioverter-defibrillator ( ICD ) , time to first ICD therapy , number of device-detected ventricular tachycardia and ventricular fibrillation episodes , AF burden , AF free interval , left ventricular function , exercise tolerance , and percentage of right ventricular pacing . CASTLE-AF will r and omize 420 patients for a minimum of 3 years at 48 sites in the United States , Europe , Australia , and South America INTRODUCTION Catheter ablation is potentially curative treatment for atrial fibrillation ( AF ) . However , complications are more frequent and more severe compared with other ablation procedures . We investigated the complication rate in 1,000 AF ablation procedures in a high-volume center and examined possible risk factors . METHODS AND RESULTS One thous and consecutive circumferential pulmonary vein radiofrequency ablations were performed for symptomatic , drug-refractory AF . Major complications were defined as the ones that were life threatening , caused permanent harm , and required intervention or prolonged hospitalization . Thirty-nine ( 3.9 % ) major periprocedural complications were observed . There was no death immediately associated with the procedure . However , there were 2 deaths ( 0.2 % ) of unclear cause , 14 days and 4 weeks after ablation . The most common complications were tamponade ( 1.3 % ) , treated mainly by percutaneous drainage , and vascular complications ( 1.1 % ) . There were also 4 thromboembolic events ( 0.4 % ) : 3 nonfatal strokes and one transient ischemic attack . Importantly , 2 cases ( 0.2 % ) of atrial-esophageal fistula and 2 cases ( 0.2 % ) of endocarditis were observed . Factors associated with an increased complication risk were age > or = 75 years ( hazard ratio 3.977 , P = 0.022 ) and congestive heart failure ( hazard ratio 5.174 , P = 0.001 ) . CONCLUSION AF ablation still has a considerable number of major complications that may be life threatening or may lead to severe residues . Atrial-esophageal fistula is still observed despite continuous systematic methods to prevent it . Stroke , tamponade , and vascular complications are the most frequent major complications . However , in most patients treatment can be conservative and results in complete recovery . Advanced age and congestive heart failure seem to be associated with an increased risk of complications 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 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 OBJECTIVES The aim of this multicenter study was to evaluate the safety of discontinuing oral anticoagulation therapy ( OAT ) after apparently successful pulmonary vein isolation . BACKGROUND Atrial fibrillation ( AF ) is associated with an increased risk of thromboembolic events ( TE ) and often requires OAT . Pulmonary vein isolation is considered an effective treatment for AF . METHODS We studied 3,355 patients , of whom 2,692 ( 79 % male , mean age 57 + /- 11 years ) discontinued OAT 3 to 6 months after ablation ( Off-OAT group ) and 663 ( 70 % male , mean age 59 + /- 11 years ) remained on OAT after this period ( On-OAT group ) . CHADS(2 ) ( congestive heart failure , hypertension , age [ 75 years and older ] , diabetes mellitus , and a history of stroke or transient ischemic attack ) risk scores of 1 and > or = 2 were recorded in 723 ( 27 % ) and 347 ( 13 % ) Off-OAT group patients and in 261 ( 39 % ) and 247 ( 37 % ) On-OAT group patients , respectively . RESULTS During follow-up ( mean 28 + /- 13 months vs. 24 + /- 15 months ) , 2 ( 0.07 % ) Off-OAT group patients and 3 ( 0.45 % ) On-OAT group patients had an ischemic stroke ( p = 0.06 ) . No other thromboembolic events occurred . No Off-OAT group patient with a CHADS(2 ) risk score of > or = 2 had an ischemic stroke . A major hemorrhage was observed in 1 ( 0.04 % ) Off-OAT group patient and 13 ( 2 % ) On-OAT group patients ( p < 0.0001 ) . CONCLUSIONS In this nonr and omized study , the risk-benefit ratio favored the suspension of OAT after successful AF ablation even in patients at moderate-high risk of TE . This conclusion needs to be confirmed by future large r and omized trials
target: AF ablation in patients with systolic LV dysfunction results in significant improvement of LV function , but the extent of this improvement is heterogeneous .
  Patients with coronary artery disease seem to benefit less than patients with other underlying diseases .
  These results may be explained by patient selection
background: BACKGROUND Atrial fibrillation ( AF ) and heart failure are often coexisting major public health burdens .
  Although several studies have reported partial restoration of systolic left ventricular ( LV ) function after catheter ablation for AF , the method is not widely applied in patients with LV dysfunction .
  We review ed the results of AF ablation in patients with systolic LV dysfunction .