title: Catheter Ablation Versus Medical Rate Control in Atrial Fibrillation and Systolic Dysfunction: The CAMERA-MRI Study. Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of symptomatic atrial fibrillation: a randomized trial. 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) Hemodynamic effects of an irregular sequence of ventricular cycle lengths during atrial fibrillation. Pulmonary-vein isolation for atrial fibrillation in patients with heart failure. Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of paroxysmal atrial fibrillation (RAAFT-2): a randomized trial. Incidence and predictors of major complications from contemporary catheter ablation to treat cardiac arrhythmias. A randomized trial to assess catheter ablation versus rate control in the management of persistent atrial fibrillation in heart failure. Atrial fibrillation is associated with an increased risk for mortality and heart failure progression in patients with asymptomatic and symptomatic left ventricular systolic dysfunction: a retrospective analysis of the SOLVD trials. Studies of Left Ventricular Dysfunction. Ablation Versus Amiodarone for Treatment of Persistent Atrial Fibrillation in Patients With Congestive Heart Failure and an Implanted Device: Results From the AATAC Multicenter Randomized Trial
abstract: BACKGROUND Atrial fibrillation ( AF ) and left ventricular systolic dysfunction ( LVSD ) frequently co-exist despite adequate rate control . Existing r and omized studies of AF and LVSD of varying etiologies have reported modest benefits with a rhythm control strategy . OBJECTIVES The goal of this study was to determine whether catheter ablation ( CA ) for AF could improve LVSD compared with medical rate control ( MRC ) where the etiology of the LVSD was unexplained , apart from the presence of AF . METHODS This multicenter , r and omized clinical trial enrolled patients with persistent AF and idiopathic cardiomyopathy ( left ventricular ejection fraction [ LVEF ] ≤45 % ) . After optimization of rate control , patients underwent cardiac magnetic resonance ( CMR ) to assess LVEF and late gadolinium enhancement , indicative of ventricular fibrosis , before r and omization to either CA or ongoing MRC . CA included pulmonary vein isolation and posterior wall isolation . AF burden post-CA was assessed by using an implanted loop recorder , and adequacy of MRC was assessed by using serial Holter monitoring . The primary endpoint was change in LVEF on repeat CMR at 6 months . RESULTS A total of 301 patients were screened ; 68 patients were enrolled between November 2013 and October 2016 and r and omized with 33 in each arm ( accounting for 2 dropouts ) .  The average AF burden post-CA was 1.6 ± 5.0 % at 6 months . In the intention-to-treat analysis , absolute LVEF improved by 18 ± 13 % in the CA group compared with 4.4 ± 13 % in the MRC group ( p < 0.0001 ) and normalized ( LVEF ≥50 % ) in 58 % versus 9 % ( p = 0.0002 ) . In those undergoing CA , the absence of late gadolinium enhancement predicted greater improvements in absolute LVEF ( 10.7 % ; p = 0.0069 ) and normalization at 6 months ( 73 % vs. 29 % ; p = 0.0093 ) . CONCLUSIONS AF is an underappreciated reversible cause of LVSD in this population despite adequate rate control . The restoration of sinus rhythm with CA results in significant improvements in ventricular function , particularly in the absence of ventricular fibrosis on CMR . This outcome challenges the current treatment paradigm that rate control is the appropriate strategy in patients with AF and LVSD . ( Catheter Ablation Versus Medical Rate Control in Atrial Fibrillation and Systolic Dysfunction [ CAMERA-MRI ] ; ACTRN12613000880741 ) CONTEXT Treatment with antiarrhythmic drugs and anticoagulation is considered first-line therapy in patients with symptomatic atrial fibrillation ( AF ) .  Pulmonary vein isolation ( PVI ) with radiofrequency ablation may cure AF , obviating the need for antiarrhythmic drugs and anticoagulation . OBJECTIVE To determine whether PVI is feasible as first-line therapy for treating patients with symptomatic AF . DESIGN , SETTING , AND PARTICIPANTS A multicenter prospect i ve r and omized study conducted from December 31 , 2001 , to July 1 , 2002 , of 70 patients aged 18 to 75 years who experienced monthly symptomatic AF episodes for at least 3 months and had not been treated with antiarrhythmic drugs . INTERVENTION Patients were r and omized to receive either PVI using radiofrequency ablation ( n=33 ) or antiarrhythmic drug treatment ( n=37 ) , with a 1-year follow-up . MAIN OUTCOME MEASURES Recurrence of AF , hospitalization , and quality of life assessment . RESULTS Two patients in the antiarrhythmic drug treatment group and 1 patient in the PVI group were lost to follow-up . At the end of 1-year follow-up , 22 ( 63 % ) of 35 patients who received antiarrhythmic drugs had at least 1 recurrence of symptomatic AF compared with 4 ( 13 % ) of 32 patients who received PVI ( P<.001 ) . Hospitalization during 1-year follow-up occurred in 19 ( 54 % ) of 35 patients in the antiarrhythmic drug group compared with 3 ( 9 % ) of 32 in the PVI group ( P<.001 ) . In the antiarrhythmic drug group , the mean ( SD ) number of AF episodes decreased from 12 ( 7 ) to 6 ( 4 ) , after initiating therapy ( P = .01 ) . At 6-month follow-up , the improvement in quality of life of patients in the PVI group was significantly better than the improvement in the antiarrhythmic drug group in 5 subclasses of the Short-Form 36 health survey . There were no thromboembolic events in either group . Asymptomatic mild or moderate pulmonary vein stenosis was documented in 2 ( 6 % ) of 32 patients in the PVI group . CONCLUSION Pulmonary vein isolation appears to be a feasible first-line approach for treating patients with symptomatic AF . Larger studies are needed to confirm its safety and efficacy 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 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 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 . IMPORTANCE Atrial fibrillation ( AF ) is the most common rhythm disorder seen in clinical practice . Antiarrhythmic drugs are effective for reduction of recurrence in patients with symptomatic paroxysmal AF .  Radiofrequency ablation is an accepted therapy in patients for whom antiarrhythmic drugs have failed ; however , its role as a first-line therapy needs further investigation . OBJECTIVE To compare radiofrequency ablation with antiarrhythmic drugs ( st and ard therapy ) in treating patients with paroxysmal AF as a first-line therapy . DESIGN , SETTING , AND PATIENTS A r and omized clinical trial involving 127 treatment-naive patients with paroxysmal AF were r and omized at 16 centers in Europe and North America to received either antiarrhythmic therapy or ablation .  The first patient was enrolled July 27 , 2006 ; the last patient , January 29 , 2010 . The last follow-up was February 16 , 2012 . INTERVENTIONS Sixty-one patients in the antiarrhythmic drug group and 66 in the radiofrequency ablation group were followed up for 24 months . MAIN OUTCOMES AND MEASURES The time to the first documented atrial tachyarrhythmia of more than 30 seconds ( symptomatic or asymptomatic AF , atrial flutter , or atrial tachycardia ) , detected by either scheduled or unscheduled electrocardiogram , Holter , transtelephonic monitor , or rhythm strip , was the primary outcome . Secondary outcomes included symptomatic recurrences of atrial tachyarrhythmias and quality of life measures assessed by the EQ-5D tool . RESULTS Forty-four patients ( 72.1 % ) in the antiarrhythmic group and in 36 patients ( 54.5 % ) in the ablation group experienced the primary efficacy outcome ( hazard ratio [ HR ] , 0.56 [ 95 % CI , 0.35 - 0.90 ] ; P = .02 ) . For the secondary outcomes , 59 % in the drug group and 47 % in the ablation group experienced the first recurrence of symptomatic AF , atrial flutter , atrial tachycardia ( HR , 0.56 [ 95 % CI , 0.33 - 0.95 ] ; P = .03 ) . No deaths or strokes were reported in either group ; 4 cases of cardiac tamponade were reported in the ablation group . In the st and ard treatment group , 26 patients ( 43 % ) underwent ablation after 1-year . Quality of life was moderately impaired at baseline in both groups and improved at the 1 year follow-up . However , improvement was not significantly different among groups . CONCLUSIONS AND RELEVANCE Among patients with paroxysmal AF without previous antiarrhythmic drug treatment , radiofrequency ablation compared with antiarrhythmic drugs result ed in a lower rate of recurrent atrial tachyarrhythmias at 2 years . However , recurrence was frequent in both groups . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00392054 BACKGROUND Up date d underst and ing of the risks of catheter ablation is important because techniques have evolved for procedures treating non-life-threatening as well as potentially lethal arrhythmias . OBJECTIVE This prospect i ve study sought to assess the incidence and predictors of major complications from contemporary catheter ablation procedures at a high-volume center . METHODS Over a 2-year period , 1,676 consecutive ablation procedures  were prospect ively evaluated for major complications throughout 30 days postprocedure . Predictors of major complications were determined in a multivariate analysis adjusted for demographics , clinical variables , ablation type , and procedural factors . RESULTS Rates of major complications differed between procedure types , ranging from 0.8 % for supraventricular tachycardia , 3.4 % for idiopathic ventricular tachycardia ( VT ) , 5.2 % for atrial fibrillation ( AF ) , and 6.0 % for VT associated with structural heart disease ( SHD ) .  Ablation type ( ablation for AF [ odds ratio ( OR ) 5.53 , 95 % confidence interval ( CI ) 1.81 to 16.83 ] , for VT with SHD [ OR 8.61 , 95 % CI 2.37 to 31.31 ] , or for idiopathic VT [ OR 5.93 , 95 % CI 1.40 to 25.05 ] all referenced to supraventricular tachycardia ablation ) , and serum creatinine level > 1.5 mg/dl ( OR 2.48 , 95 % CI 1.07 to 5.76 ) were associated with increased adjusted risk of major complications , whereas age , gender , body mass index , international normalized ratio level , hypertension , coronary artery disease , diabetes , and prior cerebrovascular accident were not associated with increased risk . CONCLUSION In a large cohort of contemporary catheter ablation  , major complication rates ranged between 0.8 % and 6.0 % depending on the ablation procedure performed . Aside from ablation type , renal insufficiency was the only independent predictor of a major complication 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 ) OBJECTIVE This study undertook to determine if the presence of atrial fibrillation in patients with asymptomatic and symptomatic left ventricular dysfunction was associated with increased mortality and , if so , whether the increase could be attributed to progressive heart failure or arrhythmic death . BACKGROUND Atrial fibrillation is a common condition in heart failure with the potential to impact hemodynamics and progression of left ventricular systolic dysfunction as well as the electrophysiologic substrate for arrhythmias . The available data do not conclusively define the effect of atrial fibrillation on prognosis in heart failure . METHODS A retrospective analysis of the Studies of Left Ventricular Dysfunction Prevention and Treatment Trials was conducted that compared patients with atrial fibrillation to those in sinus rhythm at baseline  for the risk of all-cause mortality , progressive pump-failure death and arrhythmic death . RESULTS The patients with atrial fibrillation at baseline , compared to those in sinus rhythm , had greater all-cause mortality ( 34 % vs. 23 % , p < 0.001 ) , death attributed to pump-failure ( 16.7 % vs. 9.4 % , p < 0.001 ) and were more likely to reach the composite end point of death or hospitalization for heart failure ( 45 % vs. 33 % , p < 0.001 ) , but there was no significant difference between the groups in arrhythmic deaths . After multivariate analysis , atrial fibrillation remained significantly associated with all-cause mortality ( relative risk [ RR ] 1.34 , 95 % confidence interval [ CI ] 1.12 to 1.62 , p=0.002 ) , progressive pump-failure death ( RR 1.42 , 95 % CI 1.09 to 1.85 , p=0.01 ) , the composite end point of death or hospitalization for heart failure ( RR 1.26 , 95 % CI 1.03 to 1.42 , p=0.02 ) , but not arrhythmic death ( RR 1.13 ; 95 % CI 0.75 to 1.71 ; p=0.55 ) . CONCLUSIONS The presence of atrial fibrillation in patients with asymptomatic and symptomatic left ventricular systolic dysfunction is associated with an increased risk for all-cause mortality , largely explained by an increased risk for pump-failure death . These data suggest that atrial fibrillation is associated with progression of left ventricular systolic dysfunction Background — Whether catheter ablation ( CA ) is superior to amiodarone ( AMIO ) for the treatment of persistent atrial fibrillation ( AF ) in patients with heart failure is unknown . Methods and Results — This was an open-label , r and omized , parallel-group , multicenter study . Patients with persistent AF , dual-chamber implantable cardioverter defibrillator or cardiac resynchronization therapy defibrillator , New York Heart Association II to III , and left ventricular ejection fraction < 40 % within the past 6 months were r and omly assigned ( 1:1 ratio ) to undergo CA for AF ( group 1 , n=102 ) or receive AMIO ( group 2 , n=101 ) . Recurrence of AF was the primary end point . All-cause mortality and unplanned hospitalization were the secondary end points . Patients were followed up for a minimum of 24 months . At the end of follow-up , 71 ( 70 % ; 95 % confidence interval , 60%–78 % ) patients in group 1 were recurrence free after an average of 1.4±0.6 procedures in comparison with 34 ( 34 % ; 95 % confidence interval , 25%–44 % ) in group 2 ( log-rank P<0.001 ) . The success rate  of CA in the different centers after a single procedure ranged from 29 % to 61 % . After adjusting for covariates in the multivariable model , AMIO therapy was found to be significantly more likely to fail ( hazard ratio , 2.5 ; 95 % confidence interval , 1.5–4.3 ; P<0.001 ) than CA . Over the 2-year follow-up , the unplanned hospitalization rate was ( 32 [ 31 % ] in group 1 and 58 [ 57 % ] in group 2 ; P<0.001 ) , showing 45 % relative risk reduction ( relative risk , 0.55 ; 95 % confidence interval , 0.39–0.76 ) . A significantly lower mortality was observed in CA ( 8 [ 8 % ] versus AMIO ( 18 [ 18 % ] ; P=0.037 ) . Conclusions — This multicenter r and omized study shows that CA of AF is superior to AMIO in achieving freedom from AF at long-term follow-up and reducing unplanned hospitalization and mortality in patients with heart failure and persistent AF . Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT00729911
target: Surrogate outcomes showed a similar benefit favoring CA .
  Conclusion and Relevance Catheter ablation for AF in HFrEF is associated with improvement in patient-centered outcomes and surrogate outcomes when compared to st and ard medical therapy with or without device therapy
background: Background Atrial fibrillation ( AF ) among patients with heart failure with reduced ejection fraction ( HFrEF ) is associated with adverse clinical outcomes .
  Our primary aim was to evaluate patient-centered outcomes and surrogate outcomes following catheter ablation ( CA ) of AF among patients with HFrEF compared to st and ard medical therapy with or without device therapy ( atrioventricular node ablation and cardiac resynchronization therapy ) .