title: Catheter ablation in selected patients with depressed left ventricular ejection fraction and persistent atrial fibrillation unresponsive to current cardioversion. Contact force and force-time integral in atrial radiofrequency ablation predict transmurality of lesions. Ablation vs medical therapy in the setting of symptomatic atrial fibrillation and left ventricular dysfunction. Efficacy, safety, and outcomes of catheter ablation of atrial fibrillation in patients with heart failure with preserved ejection fraction. Pulmonary vein isolation for the treatment of atrial fibrillation in patients with impaired systolic function. Atrial fibrillation in patients with heart failure: Role of catheter ablation therapies. Use and Effectiveness of Warfarin in Medicare Beneficiaries With Atrial Fibrillation Early safety and efficacy of percutaneous left atrial appendage suture ligation: results from the U.S. transcatheter LAA ligation consortium. Radiofrequency ablation for persistent atrial fibrillation in patients with advanced heart failure and severe left ventricular systolic dysfunction: a randomised controlled trial A Randomized Controlled Trial of Catheter Ablation Versus Medical Treatment of Atrial Fibrillation in Heart Failure (The CAMTAF Trial) Initial worldwide experience with the WATCHMAN left atrial appendage system for stroke prevention in atrial fibrillation. 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 Hemodynamic effects of an irregular sequence of ventricular cycle lengths during atrial fibrillation. Success of Ablation for Atrial Fibrillation in Isolated Left Ventricular Diastolic Dysfunction: A Comparison to Systolic Dysfunction and Normal Ventricular Function Pulmonary-vein isolation for atrial fibrillation in patients with heart failure. Increase in radionuclide left ventricular ejection fraction after cardioversion of chronic atrial fibrillation in idiopathic dilated cardiomyopathy. Pulmonary vein vestibule ablation for the control of atrial fibrillation in patients with impaired left ventricular function. Paroxysmal AF catheter ablation with a contact force sensing catheter: results of the prospective, multicenter SMART-AF trial. Atrial fibrillation and risk of clinical events in chronic heart failure with and without left ventricular systolic dysfunction: results from the Candesartan in Heart failure-Assessment of Reduction in Mortality and morbidity (CHARM) program. A randomized trial to assess catheter ablation versus rate control in the management of persistent atrial fibrillation in heart failure. Multicenter study on acute and long-term safety and efficacy of percutaneous left atrial appendage closure using an epicardial suture snaring device. Rhythm control versus rate control for atrial fibrillation and heart failure. Catheter ablation for atrial fibrillation in congestive heart failure. Comparison of antiarrhythmic drug therapy and radiofrequency catheter ablation in patients with paroxysmal atrial fibrillation: a randomized controlled trial.
abstract: 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 AIMS During radiofrequency ( RF ) delivery , lesion volume is highly dependent on contact force ( CF ) . It has recently been shown that changes of bipolar electrogram ( EGM ) predict transmurality . We hypothesized that there is a correlation between CF and EGM criteria of transmural lesion ( TL ) during RF . METHODS AND RESULTS We prospect ively studied consecutive 512 RF applications from atrial fibrillation ablation procedures .  A force-sensing ablation catheter ( Tacticath ( ® ) , Endosense ) was used to continuously measure CF and force-time integral ( FTI ) during each RF application . Distal bipolar EGM was analysed before , during , and after each RF application . Depending on initial EGM morphology , transmurality of lesions was defined by : ( i ) disappearance of the positivity after RF when there was QR morphology , ( ii ) diminution > 75 % of the positivity when there was QRS morphology , or ( iii ) disappearance of the R ' positivity when there was RSR ' morphology . Electrogram criteria were vali date d by electrophysiologists blinded to force measurements . Force-time integral was higher in TL than in non-transmural lesions ( NTLs ) : 652 ± 248 vs. 212 ± 140 gs ( P < 0.001 ) . Mean CF per RF pulse was higher in TL than in NTL : 26.3 ± 12.5 vs. 11.3 ± 10.3 g ( P < 0.001 ) . The best cut-off to predict TL was an FTI ≥ 392 gs [ sensitivity 0.89 , specificity ( Sp ) 0.93 , positive predictive value ( PPV ) 0.98 , and negative predictive value 0.67 ] and a higher FTI ( > 700 gs ) warrants transmurality of RF atrial lesions ( 100 % Sp and PPV ) . CONCLUSION Contact force and FTI during RF are correlated with TL . During RF delivery , a target FTI > 392 gs can be used as an endpoint 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 This study sought to investigate the efficacy and safety of catheter ablation for atrial fibrillation ( AF ) in patients with heart failure with preserved ejection fraction ( HFPEF ) . BACKGROUND AF is a precipitating factor for clinical deterioration of HFPEF . METHODS Catheter ablation for AF was performed in a consecutive 74 patients with compensated HFPEF ( left ventricular [ LV ] ejection fraction > 50 % ) . AF-free probability after catheter ablation and factors relating to maintenance of sinus rhythm were investigated . LV strain and strain rate were assessed by echocardiography at baseline and over 12 months after ablation . RESULTS During a 34 ± 16-month follow-up period , single- and multiple-procedure drug-free success rates were 27 % ( n = 20 ) and 45 % ( n = 33 ) , respectively . Multiple procedures and pharmaceutically assisted success rate was 73 % ( n = 54 ) . No major complications occurred during follow-up . Multivariate Cox regression analyses revealed that AF type ( other than long-st and ing persistent AF ) and lack of hypertension were independently associated with maintenance of sinus rhythm ( hazard ratio [ HR ] : 1.81 , 95 % confidence interval [ CI ] : 1.03 to 3.17 , p = 0.04 ; HR : 0.49 , 95 % CI : 0.24 to 0.96 , p = 0.04 , respectively ) . LV systolic indices ( LV ejection fraction , LV strain/strain rate at systole ) and diastolic indices ( E/E ' , ratio of LV strain rate at diastole with early transmitral flow ) were improved only in patients maintaining sinus rhythm at follow-up . CONCLUSIONS Our results suggest that AF can be effectively and safely treated with a composite of repeat procedures and pharmaceuticals in patients with HFPEF . However , the current study was a single-arm analysis ; therefore , larger r and omized control studies are needed to verify the benefit of AF ablation in this cohort 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 Atrial fibrillation ( AF ) represents the most common sustained cardiac arrhythmia in patients with heart failure ( HF ) . AF in HF patients is associated with worsening of symptoms and also results in a substantial increase in mortality . Although HF patients in sinus rhythm have a better outcome than patients with AF , several r and omized studies investigating pharmacological rhythm control versus rate control have shown no advantage of one strategy over the other in terms of patient outcomes . Catheter-based ablation therapy is a newer therapeutic option with a rapidly evolving and changing role in the management of this arrhythmia . In the present review , the authors discuss the epidemiology , pathophysiology and prognostic significance of AF in patients with HF . Exclusively addressed are studies investigating catheter-based ablation for rhythm-control and rate-control therapies in the management of AF in HF patients Background and Purpose — More than 2 million Americans have atrial fibrillation , and without antithrombotic therapy , their stroke rate is increased 5-fold . In r and omized controlled trials , warfarin prevented 65 % of ischemic strokes ( hazard ratio [ HR ] , 0.35 ; 95 % CI , 0.26 to 0.48 ) compared with no antithrombotic therapy . However , the effectiveness of warfarin therapy outside of clinical trials is unknown , especially in black and Hispanic population s. Our goal was to quantify use of warfarin therapy , frequency of International Normalized Ratio monitoring , and effectiveness for stroke prophylaxis in Medicare beneficiaries with atrial fibrillation . Methods — This was a cohort study of Medicare beneficiaries with atrial fibrillation who were hospitalized between March 1998 and April 1999 in all 50 US states . The primary outcome was incident hospitalizations for ischemic stroke based on vali date d International Classification of Diseases , 9th Revision , Clinical Modification codes . Results — Two thirds of ideal anticoagulation c and i date s were prescribed warfarin on hospital discharge . In unadjusted analyses , the stroke rates per 100 patient years of warfarin therapy were 5.2 in ( non-Hispanic ) white Medicare beneficiaries , 10.6 in black beneficiaries , and 12.2 in Hispanic beneficiaries . After adjusting for comorbid conditions , warfarin prescription was more frequent and monitoring more regular in white Medicare beneficiaries than in black or Hispanic beneficiaries ( P<0.0001 ) . Warfarin use was associated with 35 % fewer ischemic strokes ( HR , 0.65 ; 95 % CI , 0.55 to 0.76 ) compared with no antithrombotic therapy but was less effective in black and Hispanic beneficiaries ( P for interaction=0.048 ) . Conclusions — The use , monitoring , and effectiveness of warfarin therapy are suboptimal in Medicare beneficiaries , especially in black and Hispanic beneficiaries BACKGROUND Transcatheter left atrial appendage ( LAA ) ligation may represent an alternative to oral anticoagulation for stroke prevention in atrial fibrillation . OBJECTIVES This study sought to assess the early safety and efficacy of transcatheter ligation of the LAA for stroke prevention in atrial fibrillation . METHODS This was a retrospective , multicenter study of consecutive patients undergoing LAA ligation with the Lariat device at 8 U.S. sites . The primary endpoint was procedural success , defined as device success ( suture deployment and < 5 mm leak by post-procedure transesophageal echocardiography ) , and no major complication at discharge ( death , myocardial infa rct ion , stroke , Bleeding Academic Research Consortium bleeding type 3 or greater , or cardiac surgery ) . Post-discharge management was per operator discretion . RESULTS A total of 154 patients were enrolled .  Median CHADS2 score ( congestive heart failure , hypertension , age ≥ 75 years , diabetes mellitus , prior stroke , transient ischemic attack , or thromboembolism [ doubled ] ) was 3 ( interquartile range : 2 to 4 ) . Device success was 94 % , and procedural success was 86 % . A major complication occurred in 15 patients ( 9.7 % ) . There were 14 major bleeds ( 9.1 % ) , driven by the need for transfusion ( 4.5 % ) . Significant pericardial effusion occurred in 16 patients ( 10.4 % ) . Follow-up was available in 134 patients at a median of 112 days ( interquartile range : 50 to 270 days ) : Death , myocardial infa rct ion , or stroke occurred in 4 patients ( 2.9 % ) . Among 63 patients with acute closure and transesophageal echocardiography follow-up , there were 3 thrombi ( 4.8 % ) and 13 ( 20 % ) with residual leak . CONCLUSIONS In this initial multicenter experience of LAA ligation with the Lariat device , the rate of acute closure was high , but procedural success was limited by bleeding . A prospect i ve r and omized trial is required to adequately define clinical efficacy , optimal post-procedure medical therapy , and the effect of operator experience on procedural safety 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 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 : OBJECTIVES This study assessed the feasibility of implanting a device in the left atrial appendage ( LAA ) in patients with atrial fibrillation ( AF ) to prevent thromboembolic stroke . BACKGROUND Meta-analyses confirmed that in cases of left atrial thrombus in nonrheumatic AF patients approximately 90 % of them are in the LAA . METHODS The WATCHMAN Left Atrial Appendage System ( Atritech Inc. , Plymouth , Minnesota ) is a nitinol device implanted percutaneously to seal the LAA . Patients were followed by clinical and transesophageal echocardiography at 45 days and 6 months with annual clinical follow-up thereafter . RESULTS Sixty-six patients underwent device implantation . Mean follow-up was 740 + /- 341 days . At 45 days , 93 % ( 54 of 58 ) devices showed successful sealing of LAA according to protocol . Two patients experienced device embolization , both successfully retrieved percutaneously . No embolizations occurred in 53 patients enrolled after modification of fixation barbs . There were 2 cardiac tamponades , 1 air embolism , and 1 delivery wire fracture ( first generation ) with surgical explantation but no long-term sequelae for the patient . Four patients developed a flat thrombus layer on the device at 6 months that resolved with additional anticoagulation . Two patients experienced transient ischemic attack , 1 without visible thrombus . There were 2 deaths , neither device related . Autopsy documented a stable , fully endothelialized device 9 months after implantation . No strokes occurred during follow-up despite > 90 % of patients with discontinuation of anticoagulation . CONCLUSIONS Preliminary data suggest LAA occlusion with the WATCHMAN System to be safe and feasible . A r and omized study is ongoing comparing oral anticoagulation with percutaneous closure 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 OBJECTIVES The aim of this study was to determine the independent hemodynamic effects of an irregular sequence of ventricular cycle lengths in patients with atrial fibrillation ( AF ) . BACKGROUND Atrial fibrillation may reduce cardiac output by several possible mechanisms , including loss of the atrial contribution to left ventricular filling , valvular regurgitation , increased ventricular rate or irregular RR intervals . This study was design ed to evaluate the effects of an irregular RR interval , independent of the average ventricular rate , on cardiac hemodynamic data during AF . METHODS Sixteen patients with AF were studied invasively . During intrinsically conducted AF ( mean rate 102 + /- 22 beats/ min ) , the right ventricular apex electrogram was recorded onto frequency-modulated ( FM ) tape . After atrioventricular node ablation , the right ventricular apex was stimulated in three pacing modes in r and omized sequence : 1 ) VVI at 60 beats/min ; 2 ) VVI at the same average rate as during intrinsically conducted AF ( 102 + /- 22 beats/min ) ; and 3 ) during VVT pacing in which the pacemaker was triggered by playback of the FM tape recording of the right ventricular apex electrogram previously recorded during intrinsically conducted AF ( VVT 102 + /- 22 beats/min ) . RESULTS Compared with VVI pacing at the same average rate , an irregular sequence of RR intervals decreased cardiac output ( 4.4 + /- 1.6 vs. 5.2 + /- 2.4 liters/min , p < 0.01 ) , increased pulmonary capillary wedge pressure ( 17 + /- 7 vs. 14 + /- 6 mm Hg , p < 0.002 ) and increased right atrial pressure ( 10 + /- 6 vs. 8 + /- 4 mm Hg , p < 0.05 ) . CONCLUSIONS An irregular sequence of RR intervals produces adverse hemodynamic consequences that are independent of heart rate Background — The efficacy of radiofrequency ablation for atrial fibrillation ( AF ) in patients with left ventricular ( LV ) systolic dysfunction and isolated diastolic dysfunction is uncertain . Methods and Results — A prospect i ve cohort of patients with normal and abnormal LV function underwent ablation for antiarrhythmic drug (AAD)-refractory AF . Three groups were compared : 111 patients with systolic dysfunction , defined as LV ejection fraction ( LVEF ) ⩽40 % ; 157 patients with isolated diastolic dysfunction but preserved LVEF ≥50 % ; and 100 patients with normal LV function . The primary end point was AAD-free AF elimination at 1 year after ablation . This end point was achieved in 62 % of patients with systolic dysfunction , 75 % of those with diastolic dysfunction , and 84 % of controls ( P=0.007 ) . AF control on or off AADs was achieved in 76 % of patients with systolic dysfunction , 85 % of those with diastolic dysfunction , and 89 % of controls ( P=0.08 ) . In the systolic dysfunction group , 49 % experienced an increase in LVEF by ≥5 % after ablation , of which 64 % achieved normal LVEF . In the diastolic dysfunction group , 30 % of patients demonstrated at least 1 grade improvement in diastolic dysfunction . Multivariable analysis demonstrated an increased relative risk of arrhythmia recurrence of 1.8 ( 95 % CI , 1.1 to 3.1 ; P=0.02 ) in systolic dysfunction and 1.7 ( 1.0 to 2.7 ; P=0.04 ) in isolated diastolic dysfunction compared with normal function . Conclusions — Although an ablative approach for AF in patients with systolic or diastolic dysfunction is associated with an increased long-term recurrence risk , there is potential for substantial quality -of-life improvement and LV functional benefit 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 . To assess the potential improvement in left ventricular ejection fraction after cardioversion of  chronic atrial fibrillation  to sinus rhythm in idiopathic dilated cardiomyopathy , we studied prospect ively 17 patients , aged 58 + /- 6 years , by radionuclide angiocardiography at rest .  Left ventricular ejection fraction was determined before treatment and at a mean delay of 4.7 months after cardioversion . Return to sinus rhythm was obtained in 12 patients , pharmacologically or by electrical cardioversion . Five patients remained in atrial fibrillation . No clinical , echocardiographic or haemodynamic finding could predict the success of cardioversion . In chronic atrial fibrillation , the ejection fraction did not change significantly : 30.0 + /- 9.1 % ( 19 to 44 % ) at the first evaluation and 29.5 + /- 8.3 % ( 22 to 41 % ) after 4.7 months . After successful cardioversion , left ventricular ejection fraction improved from 32.1 + /- 5.3 % ( 24 to 41 % ) to 52.9 + /- 9.7 % ( 37 to 71 % ) ( P less than 0.001 ) . The difference was 20.8 + /- 11.3 % and left ventricular ejection fraction was normalized in 50 % ( 6/12 ) of the patients . There was a significant reduction in the cardiothoracic ratio on chest X-rays and of the left ventricular end-diastolic diameter on echocardiography ; fractional shortening increased ( 27.7 + /- 4.3 % vs 20.3 + /- 2.7 % , P less than 0.01 ) . A third evaluation was realized after a mean delay of 11.7 months in the patients with successful cardioversion . Sinus rhythm was present in 83 % ( 10/12 ) of the patients : seven patients were reevaluated by radionuclide angiography . The improvement in left ventricular function observed at the 4.7 months evaluation was still present . In two patients with recurrence of atrial fibrillation , there was a severe deterioration of left ventricular systolic function . ( ABSTRACT TRUNCATED AT 250 WORDS 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 Catheter ablation is important for treatment of paroxysmal atrial fibrillation ( PAF ) . Limited animal and human studies suggest a correlation between electrode-tissue contact and radiofrequency lesion generation . OBJECTIVES The study sought to assess the safety and effectiveness of an irrigated , contact force (CF)-sensing catheter in the treatment of drug refractory symptomatic PAF . METHODS A prospect i ve , multicenter , nonr and omized study was conducted . Enrollment criteria included : ≥3 symptomatic episodes of PAF within 6 months of enrollment and failure of ≥1 antiarrhythmic drug ( Class I to IV ) . Ablation included pulmonary vein isolation with confirmed entrance block as procedural endpoint . RESULTS A total of 172 patients were enrolled at 21 sites , where 161 patients had a study catheter inserted and 160 patients underwent radiofrequency application . Procedural-related serious adverse events occurring within 7 days of the procedure included tamponade ( n = 4 ) , pericarditis ( n = 3 ) , heart block ( n = 1 , prior to radiofrequency application ) , and vascular access complications ( n = 4 ) . By Kaplan-Meier analyses , 12-month freedom from atrial fibrillation/atrial flutter/atrial tachycardia recurrence was 72.5 % . The average CF per procedure was 17.9 ± 9.4 g. When the CF employed was between investigator selected working ranges ≥80 % of the time during therapy , outcomes were 4.25 times more likely to be successful ( p = 0.0054 ; 95 % confidence interval : 1.53 to 11.79 ) . CONCLUSIONS The SMART-AF trial demonstrated that this irrigated CF-sensing catheter is safe and effective for the treatment of drug refractory symptomatic PAF , with no unanticipated device-related adverse events . The increased percent of time within investigator-targeted CF ranges correlates with increased freedom from arrhythmia recurrence . Stable CF during radiofrequency application increases the likelihood of 12-month success . ( THERMOCOOL ® SMARTTOUCH ® Catheter for Treatment of Symptomatic Paroxysmal Atrial Fibrillation ; NCT01385202 ) OBJECTIVES We assessed the risk of adverse cardiovascular ( CV ) outcomes associated with atrial fibrillation ( AF ) in the C and esartan in Heart failure- Assessment of Reduction in Mortality and morbidity ( CHARM ) program , which enrolled patients with chronic heart failure ( CHF ) and a broad range of ejection fractions ( EFs ) . BACKGROUND Atrial fibrillation is associated with an increased risk of adverse CV outcomes in patients with CHF and reduced EF . The risk of AF in patients with CHF and preserved left ventricular ejection fraction ( PEF ) is unknown . METHODS A total of 7,599 patients with symptomatic CHF were r and omized to c and esartan or placebo . Patients were divided by baseline EF ( < or = 40 % or > 40 % ) in low or preserved EF groups . Major outcomes were cardiovascular death or hospitalization for worsening heart failure , and all-cause mortality . Median follow-up was 37.7 months . RESULTS A total of 670 ( 17 % ) patients in the low EF group and 478 ( 19 % ) in the PEF group had AF at baseline . Atrial fibrillation predicted a high risk of cardiovascular morbidity and mortality regardless of baseline EF . Patients with AF and low EF had the highest absolute risk for adverse CV outcomes . However , AF was associated with greater relative increased risk of the major outcomes in patients with PEF than in patients with low EF : hazard ratio 1.72 ( 95 % confidence interval [ CI ] 1.45 to 2.06 ) versus 1.29 ( 95 % CI 1.14 to 1.46 ) , respectively . The same was true for the risk of all-cause mortality . C and esartan was associated with similar treatment effects regardless of baseline rhythm . CONCLUSIONS Atrial fibrillation is associated with an increased risk of CV outcomes in patients with CHF and either reduced EF or PEF . C and esartan improved outcomes similarly regardless of baseline rhythm 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 Pericardial suture ligation of the left atrial appendage ( LAA ) may be an alternative to endoluminal devices for stroke prevention in patients with atrial fibrillation , but multicenter safety and efficacy data in high-risk patients with contraindications to oral anticoagulation are lacking . OBJECTIVE The purpose of this study was to report the outcomes of consecutive cases of pericardial suture ligation of the LAA in high-risk patients performed at 4 centers . METHODS The cohort included 41 consecutive patients who underwent LAA closure with the LARIAT system .  Epicardial and transeptal access was obtained , and the epicardial snare was advanced over an endo-epicardial magnetic-tipped guidewire to close the LAA . Transesophageal echocardiography was used to confirm LAA exclusion . RESULTS Mean age was 75 ± 10 years , mean CHADS2 score was 3.0 ± 1.3 , and mean HAS-BLED score was 4.4 ± 1.4 . These patients accumulated 24.6 person-years of follow-up . Acute LAA closure was achieved in 38 patients ( 93 % ) . Transesophageal echocardiography or computerized tomographic angiography performed up to 3.3 ± 0.8 months after the procedure demonstrated LAA leakage in 24 % of patients . One patient ( 2 % ) had a transient ischemic attack , and 8 ( 20 % ) developed pericardial effusions requiring pericardiocentesis . Four cases ( 9 % ) were complicated by perforation of the LAA , with 2 of these patients requiring open surgical correction . CONCLUSION This multicenter experience revealed that pericardial suture ligation with the LARIAT system is technically feasible and acutely efficacious . However , additional improvements are required to minimize the rate of pericardial complications . A r and omized study is warranted to accurately define the long-term efficacy and safety profile of percutaneous epicardial suture ligation BACKGROUND It is common practice to restore and maintain sinus rhythm in patients with atrial fibrillation and heart failure . This approach is based in part on data indicating that atrial fibrillation is a predictor of death in patients with heart failure and suggesting that the suppression of atrial fibrillation may favorably affect the outcome . However , the benefits and risks of this approach have not been adequately studied . METHODS We conducted a multicenter , r and omized trial comparing the maintenance of sinus rhythm ( rhythm control ) with control of the ventricular rate ( rate control ) in patients with a left ventricular ejection fraction of 35 % or less , symptoms of congestive heart failure , and a history of atrial fibrillation . The primary outcome was the time to death from cardiovascular causes . RESULTS A total of 1376 patients were enrolled ( 682 in the rhythm-control group and 694 in the rate-control group ) and were followed for a mean of 37 months . Of these patients , 182 ( 27 % ) in the rhythm-control group died from cardiovascular causes , as compared with 175 ( 25 % ) in the rate-control group ( hazard ratio in the rhythm-control group , 1.06 ; 95 % confidence interval , 0.86 to 1.30 ; P=0.59 by the log-rank test ) . Secondary outcomes were similar in the two groups , including death from any cause ( 32 % in the rhythm-control group and 33 % in the rate-control group ) , stroke ( 3 % and 4 % , respectively ) , worsening heart failure ( 28 % and 31 % ) , and the composite of death from cardiovascular causes , stroke , or worsening heart failure ( 43 % and 46 % ) . There were also no significant differences favoring either strategy in any predefined subgroup . CONCLUSIONS In patients with atrial fibrillation and congestive heart failure , a routine strategy of rhythm control does not reduce the rate of death from cardiovascular causes , as compared with a rate-control strategy . ( Clinical Trials.gov number , NCT00597077 . 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 CONTEXT Antiarrhythmic drugs are commonly used for prevention of recurrent atrial fibrillation ( AF ) despite inconsistent efficacy and frequent adverse effects . Catheter ablation has been proposed as an alternative treatment for paroxysmal AF . OBJECTIVE To determine the efficacy of catheter ablation compared with antiarrhythmic drug therapy ( ADT ) in treating symptomatic paroxysmal AF . DESIGN , SETTING , AND PARTICIPANTS A prospect i ve , multicenter , r and omized ( 2:1 ) , unblinded , Bayesian- design ed study conducted at 19 hospitals of 167 patients who did not respond to at least 1 antiarrhythmic drug and who experienced at least 3 AF episodes within 6 months before r and omization . Enrollment occurred between October 25 , 2004 , and October 11 , 2007 , with the last follow-up on January 19 , 2009 . INTERVENTION Catheter ablation ( n = 106 ) or ADT ( n = 61 ) , with assessment for effectiveness in a comparable 9-month follow-up period . MAIN OUTCOME MEASURES Time to protocol -defined treatment failure . The proportion of patients who experienced major treatment-related adverse events within 30 days of catheter ablation or ADT was also reported . RESULTS At the end of the 9-month effectiveness evaluation period , 66 % of patients in the catheter ablation group remained free from protocol -defined treatment failure compared with 16 % of patients treated with ADT . The hazard ratio of catheter ablation to ADT was 0.30 ( 95 % confidence interval , 0.19 - 0.47 ; P < .001 ) . Major 30-day treatment-related adverse events occurred in 5 of 57 patients ( 8.8 % ) treated with ADT and 5 of 103 patients ( 4.9 % ) treated with catheter ablation .  Mean quality of life scores improved significantly in patients treated by catheter ablation compared with ADT at 3 months ; improvement was maintained during the course of the study . CONCLUSION Among patients with paroxysmal AF who had not responded to at least 1 antiarrhythmic drug , the use of catheter ablation compared with ADT result ed in a longer time to treatment failure during the 9-month follow-up period . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00116428
target: RECENT FINDINGS Several r and omized control trials and systematic review s demonstrate the safety and efficacy of atrial fibrillation ablation in patients with heart failure and left ventricular systolic dysfunction .
  In multiple trials , these patients have shown clinical benefit from atrial fibrillation ablation including improved left ventricular systolic function , quality of life , and clinical heart failure symptoms .
  SUMMARY Atrial fibrillation ablation in heart failure patients remains well tolerated with an overall efficacy comparable to atrial fibrillation ablation in patients without heart failure .
  There is consistent evidence for the clinical benefit of atrial fibrillation ablation in heart failure patients with left ventricular systolic dysfunction and limited evidence for atrial fibrillation ablation in heart failure patients with preserved ejection fraction .
  Currently , there is insufficient data regarding the safety and efficacy of left atrial appendage closure devices in heart failure patients
background: PURPOSE OF REVIEW Patients with atrial fibrillation and heart failure experience an increased morbidity and mortality from the hemodynamic consequences of atrial fibrillation and an increased stroke risk .
  Consequently , there has been increased attention to procedural alternatives to pharmacologic rhythm control and anticoagulation for stroke prevention .
  This review aims to evaluate the evidence for atrial fibrillation ablation and left atrial appendage closure in heart failure patients .