Efficacy, safety, and outcomes of catheter ablation of atrial fibrillation in patients with heart failure with preserved ejection fraction. Atrial fibrillation in patients with heart failure: Role of catheter ablation therapies. A Randomized Controlled Trial of Catheter Ablation Versus Medical Treatment of Atrial Fibrillation in Heart Failure (The CAMTAF Trial) Optimal heart failure therapy and successful cardioversion in heart failure patients with atrial fibrillation. Outcomes of cardiac resynchronization therapy in patients with intermittent atrial fibrillation or atrial flutter in the COMPANION trial. Impact of Atrial Fibrillation on Exercise Capacity in Heart Failure With Preserved Ejection Fraction: A RELAX Trial Ancillary Study A prospective, multicenter evaluation of ablating complex fractionated electrograms (CFEs) during atrial fibrillation (AF) identified by an automated mapping algorithm: acute effects on AF and efficacy as an adjuvant strategy. Catheter ablation in selected patients with depressed left ventricular ejection fraction and persistent atrial fibrillation unresponsive to current cardioversion. 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. 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. Sinus rhythm restoration by catheter ablation in patients with long-lasting atrial fibrillation and congestive heart failure: impact of the left ventricular ejection fraction improvement on the implantable cardioverter defibrillator insertion indication. Catheter ablation of atrial fibrillation in patients with atrial septal defect: long-term follow-up results A randomized clinical trial of early invasive intervention for atrial fibrillation (EARLY-AF) - methods and rationale. Catheter ablation versus standard conventional treatment in patients with left ventricular dysfunction and atrial fibrillation (CASTLE-AF) - study design. Phased RF ablation in persistent atrial fibrillation. Pulmonary vein vestibule ablation for the control of atrial fibrillation in patients with impaired left ventricular function. Atrial Fibrillation in Heart Failure With Preserved Ejection Fraction: The TOPCAT Trial.
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 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 —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 : BACKGROUND Effectiveness , safety , and other factors associated with success of cardioversion ( CV ) of atrial fibrillation ( AF )  have not yet been evaluated in patients with reduced left ventricular ejection fraction . We studied 148 consecutive patients with left ventricular dysfunction ( ejection fraction < or = 45 % ) , who underwent electrical CV for AF in our department . The patients had New York Heart Association heart failure ranging from class II to IV . The overall CV success rate was 71 % . We relied on univariate and multivariate regression and sought variables influencing success rate . Conversion success did not correlate with New York Heart Association class . Instead , we found that the greatest predictor was the degree of heart failure treatment . Patients receiving beta-blockers , angiotensin-converting enzyme inhibitors or angiotension receptor blockers , plus mineralocorticoid receptor blockers had the greatest chance for conversion success . Success was more likely in patients with coronary artery disease ( 91 % ) than in patients with nonischemic cardiomyopathy . CONCLUSIONS Cardioversion is a safe and effective method for the restoration of sinus rhythm in patients with AF and reduced left ventricular ejection fraction . Our findings underscore the value of aggressive heart failure treatment before CV in patients with AF BACKGROUND Controlled clinical trial data are lacking for cardiac resynchronization therapy ( CRT ) outcomes in patients with advanced heart failure ( HF ) from reduced left ventricular ejection fraction ( HFrEF ) and intermittent atrial fibrillation or flutter ( IAF/AFL ) . OBJECTIVE The purpose of this study was to describe CRT outcomes in patients with IAF/AFL and advanced HF . METHODS HF outcomes in patients in the COMPANION ( Comparison of Medical Therapy , Pacing , and Defibrillation in Heart Failure ) trial with New York Heart Association class III or IV HFrEF , left ventricular ejection fraction ≤0.35 , sinus rhythm at r and omization , and no history of baseline arrhythmia were compared with those with a history of IAF/AFL . RESULTS In those with no history of baseline arrhythmia ( n = 887 ) , compared with optimal pharmacological therapy ( OPT ) with no CRT , the CRT + OPT arms exhibited a significant reduction in the end points of death or any hospitalization ( hazard ratio [ HR ] 0.73 [ 95 % Confidence Interval ( CI ) : 0.60 to 0.89 ] ; P = .002 ) and death or HF hospitalization ( HR 0.53 [ 95 % CI : 0.41 to 0.68 ] ; P < .001 ) . In contrast , in the IAF/AFL subgroup ( n = 293 ) , CRT did not result in improved outcomes compared with OPT ( death or any hospitalization : HR 1.16 [ 95 % CI : 0.83 to 1.63 ] ; P = .38 ; death or HF hospitalization : HR 0.97 [ 95 % CI : 0.64 to 1.46 ] ; P = .88 ) . The interaction between history of AF/AFL and CRT was statistically significant for both outcomes ( P < .05 ) . CONCLUSION In the COMPANION trial , patients with moderate to severe HFrEF and a history of IAF/AFL had no benefit from CRT Background — Atrial fibrillation ( AF ) is common among patients with heart failure and preserved ejection fraction ( HFpEF ) , but its clinical profile and impact on exercise capacity remain unclear . RELAX ( Phosphodiesterase-5 Inhibition to Improve Clinical Status and Exercise Capacity in HFpEF ) was a multicenter r and omized trial testing the impact of sildenafil on peak VO2 in stable out patients with chronic HFpEF . We sought to compare clinical features and exercise capacity among patients with HFpEF who were in sinus rhythm ( SR ) or AF . Methods and Results — RELAX enrolled 216 patients with HFpEF , of whom 79 ( 37 % ) were in AF , 124 ( 57 % ) in SR , and 13 in other rhythms . Participants underwent baseline cardiopulmonary exercise testing , echocardiogram , biomarker assessment , and rhythm status assessment before r and omization . Patients with AF were older than those in SR but had similar symptom severity , comorbidities , and renal function . & bgr;-blocker use and chronotropic indices were also similar . Despite comparable left ventricular size and mass , AF was associated with worse systolic ( lower EF , stroke volume , and cardiac index ) and diastolic ( shorter deceleration time and larger left atria ) function compared with SR . Pulmonary artery systolic pressure was higher in AF . Patients with AF had higher N-terminal pro-B-type natriuretic peptide , aldosterone , endothelin-1 , troponin I , and C-telopeptide for type I collagen levels , suggesting more severe neurohumoral activation , myocyte necrosis , and fibrosis . Peak VO2 was lower in AF , even after adjustment for age , sex , and chronotropic response , and VE/VCO2 was higher . Conclusions — AF identifies an HFpEF cohort with more advanced disease and significantly reduced exercise capacity . These data suggest that evaluation of the impact of different rate or rhythm control strategies on exercise tolerance in patients with HFpEF and AF is warranted . Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT00763867 BACKGROUND Complex fractionated electrograms ( CFEs ) are continuous electrograms ( EGMs ) of very short cycle length ( CL ) representing substrate for atrial fibrillation ( AF ) perpetuation . Ablation of CFEs may result in AF slowing , termination , and prevention , but identifying them can be subjective . OBJECTIVE The purpose of this study was to prospect ively assess ( 1 ) whether an automated algorithm can identify CFE regions , ( 2 ) the acute effects of ablating these regions on AF , and ( 3 ) the long-term efficacy as an adjuvant strategy to pulmonary vein antrum isolation ( PVAI ) . METHODS Thirty-five patients ( three centers , 61 + /- 9 years , left atrium [ LA ] 43 + /- 9 mm , ejection fraction 53 % + /- 7 % ) with symptomatic paroxysmal ( n = 21 ) or persistent ( n = 14 ) AF were studied . A decapolar lasso ( 2-mm spacing ) was used for mapping . A three-dimensional shell of the LA and pulmonary veins ( PVs ) was created . If not already in AF , AF was induced by burst pacing ( with or without isoproterenol ) . Atrial EGMs during AF were mapped/analyzed using an automated CFE algorithm . The algorithm measures the time between discrete deflections in a local EGM over 5 seconds ( based on selectable width and peak-to-peak [ > 0.03 mV ] criteria ) . The mean CL of the local EGM is projected onto the LA shell as a color-coded display . Regions of CL < 120 ms ( published criteria ) were targeted for ablation/elimination . Atrial fibrillation cycle length ( AFCL ) and regularity were measured from the CS . After CFE ablation , further ablation was done to achieve complete PVAI . RESULTS AF was spontaneous ( n = 20 ) or induced ( n = 15 ) in all patients . CFEs were most commonly found along the septum ( 97 % ) , anterior LA ( 97 % ) , PV antra ( 83 % ) , base of appendage ( 83 % ) , and annulus ( 71 % ) . CFE ablation alone prolonged the AFCL ( 171 + /- 27 vs. 304 + /- 41 ms ; P = .03 ) and regularized AF to left/right flutter ( AFL ) in 74 % of patients . CFE ablation terminated AF/AFL in 19 patients (54%)-the other 16 were cardioverted- and AF became noninducible in 77 % . CFE ablation alone did not cause PV isolation ( 0.1 + /- 0.3 PV isolated/patient ) . After combined CFE and PVAI ablation , the single-procedure , off-drug success rate was 83 % ( follow-up 13 + /- 4 months ) versus 71 % in matched controls who had PVAI alone ( P = .045 ) . CONCLUSIONS CFE ablation guided by an automated algorithm result ed in AFCL prolongation , regularization , and noninducibility in most patients . AF terminated in 54 % of cases . PVAI with adjuvant CFE ablation has a high efficacy and may be superior to PVAI alone 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 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 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 AIMS In the setting of congestive heart failure ( CHF ) , atrial fibrillation ( AF ) ablation can improve clinical status and the left ventricular ejection fraction ( LVEF ) value . However , the impact of AF ablation on the implantable cardioverter defibrillator ( ICD ) indication has never been specifically addressed . METHODS AND RESULTS Study subject were six CHF ( mean age 61.1 + /- 6.9 years , mean LVEF 25.8 + /- 7.3 % ) patients refractory to conventional medical treatment with long-lasting AF unresponsive to external cardioversion . Five patients had an idiopathic dilated cardiomyopathy ( DCM ) and one had an ischaemic cardiomyopathy ( ICM ) . Their New York Heart Association ( NYHA ) class was III-IV . Two patients had renal insufficiency . No patient had left ventricular delay . All patients underwent AF ablation .  LVEF and NYHA class were dramatically improved in the five DCM patients . New York Heart Association class , but not the LVEF , was improved in the ICM patient . A redo ablative procedure was undertaken in four of five DCM patients and in the ICM patient due to arrhythmia recurrence . Left ventricular ejection fraction and NYHA were improved again in the DCM patients ( 56 + /- 4.4 % , I-II , respectively ) and led to ICD indication preclusion . The LVEF remained low in the ICM patient ( 30 % ) and led to ICD insertion . Sinus rhythm has been stable during the 18.1 + /- 5.7 months follow-up period . CONCLUSION  Atrial fibrillation ablation in CHF patients can improve both the clinical status of patients and their LVEF , especially among those affected by DCM . The LVEF improvement has the potential to preclude the indication for a primary prevention ICD insertion Introduction Atrial fibrillation ( AF ) is commonly found in patients with structural heart disease ( SHD ) , including atrial septal defect ( ASD ) . The feasibility and safety of ablation for AF in patients with unrepaired ASD is seldom reported . Objectives This study aims to evaluate and compare the long-term efficacy of  AF ablation  in patients with and without ASD . Methods From January 2008 to December 2012 , 18 consecutive patients were identified with medically refractory AF and an unrepaired ASD under catheter ablation .  For each ASD patient , four control subjects were matched from our data base . Results There were no significant differences between groups in terms of age , sex , type of AF , LA diameter , LVIDD , and EF . The mean procedural and fluoroscopy times were not different between the groups ( p = NS ) . After a median follow-up of 20 months , the patients in the ASD group had 44.4 % AF recurrence after a single procedure compared with 34.7 % in the control group ( p = 0.11 ) . The mean LA diameter in non-recurrent patients was smaller than in recurrent patients ( p = 0.03 ) . In univariate Cox proportional hazards analyses , the factor found to have a significant association with arrhythmia recurrences was left atrial diameter ( hazard ratio 1.059 , 95 % confidence interval 1.002 to 1.120 , p = 0.03 ) . Conclusions These results indicate that in patients with AF and an ASD amenable to percutaneous closure , a staged approach with radiofrequency ablation of AF preceding closure is a rational strategy BACKGROUND The ideal management of patients with newly diagnosed symptomatic atrial fibrillation ( AF ) remains unknown . Current practice guidelines recommend a trial of antiarrhythmic drugs ( AAD ) prior to considering an invasive ablation procedure . However , earlier ablation offers an opportunity to halt the progressive patho-anatomical changes associated with AF , as well as impart other important clinical benefits . OBJECTIVE The aim of this study is to determine the optimal initial management strategy for patients with newly diagnosed , symptomatic atrial fibrillation . METHODS / DESIGN The EARLY-AF study ( Clinical Trials.govNCT02825979 ) is a prospect i ve , open label , multicenter , r and omized trial with a blinded assessment of outcomes . A total of 298 patients will be r and omized in a 1:1 fashion to first-line AAD therapy , or first-line cryoballoon-based pulmonary vein isolation .  Patients with symptomatic treatment naïve AF will be included . Arrhythmia outcomes will be assessed by implantable cardiac monitor ( ICM ) . The primary outcome is time to first recurrence of AF , atrial flutter , or atrial tachycardia ( AF/AFL/AT ) between days 91 and 365 following AAD initiation or AF ablation . Secondary outcomes include arrhythmia burden , quality of life , and healthcare utilization . DISCUSSION The EARLY-AF study is a r and omized trial design ed to evaluate the optimal first management approach for patients with AF . We hypothesize that catheter ablation will be superior to drug therapy in prevention of AF recurrence 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 BACKGROUND Persistent and long-st and ing persistent atrial fibrillation ( AF ) often requires extensive and /or repeat radiofrequency ( RF ) ablation procedures . OBJECTIVE The Tailored Treatment of Persistent Atrial Fibrillation ( TTOP-AF ) study assessed the effectiveness and safety of the phased RF system in a r and omized controlled comparison of medical therapy against phased RF ablation for the management of persistent and long-st and ing persistent AF . METHODS Patients who had failed at least 1 antiarrhythmic drug ( AAD ) were r and omized ( 2:1 ) to ablation management ( AM ) or medical management ( MM ) . AM patients were allowed up to 2 ablations . Index and retreatment procedures consisted of pulmonary vein isolation and ablation of complex fractionated atrial electrograms . MM patients received AAD changes and /or cardioversion . The primary end points of the TTOP-AF study included chronic effectiveness and safety at 6 months and acute safety within 7 days of ablation . RESULTS At 6 months , a greater proportion of AM patients achieved effectiveness off AAD ( 77 of 138 [ 55.8 % ] ) compared to MM patients ( 19 of 72 [ 26.4 % ] ) ( P < .0001 ) . Acutely , 92.8 % ( 128/138 ) of the procedures were successful while 12.3 % ( 17/138 ) experienced a serious procedure and /or device-related adverse event . The predefined acute safety end point was not met . The proportion of patients with chronic safety events did not differ significantly between groups . CONCLUSIONS Catheter ablation of persistent/long-st and ing persistent AF with the phased RF ablation system is effective with greater reduction of AF compared with MM . More intense anticoagulation strategies , careful attention to catheter placement relative to the pulmonary vein ostia , and elimination of electrode interaction are expected to reduce the risk of stroke , pulmonary vein stenosis , and asymptomatic cerebral emboli INTRODUCTION Congestive heart failure ( CHF ) and atrial fibrillation ( AF ) are frequently linked , and when associated produce additive deleterious effects . In this prospect i ve study , the effects of catheter ablation for AF  in patients with impaired left ventricular ( LV ) function are presented . METHODS Baseline data and clinical outcome have been prospect ively collected in 105 consecutive patients who underwent pulmonary vein ablation for the control of AF .  We evaluated 40 patients affected by LV dysfunction with ejection fraction (EF)<40 % and compared them to the remaining 65 patients with normal ventricular function in terms of changes in LV function , maintenance of sinus rhythm , and quality of life during follow-up . RESULTS After a mean follow-up of 14+/-2 months , 87 % of patients with impaired LV function and 92 % of patients with normal ventricular function were in sinus rhythm , with or without antiarrhythmic therapy ( P = NS ) . A significant improvement in LVEF and fractional shortening was documented in patients with CHF ( 33+/-2 % vs 47+/-3 % , and 19+/-4 % vs 30+/-3 % , P<0.01 for both comparisons ) . Evaluation of exercise capacity and quality of life documented better improvements in patients with CHF compared to patients without CHF . CONCLUSIONS Catheter ablation in patients with LV dysfunction is feasible , not associated with higher procedural complications , and provides a significant improvement in LV performance , symptoms , and quality of life during follow-up OBJECTIVES This study assessed the relationship between atrial fibrillation ( AF ) and outcomes in the TOPCAT ( Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist ) trial , to evaluate whether AF modified the treatment response to spironolactone and whether spironolactone influenced post-r and omization AF . BACKGROUND AF is common in heart failure with preserved ejection fraction ( HFpEF ) and likely contributes to increased risk of adverse outcomes . METHODS A total 1,765 patients enrolled in TOPCAT trial in North and South America were divided into 3 groups : no known AF , history of AF without AF at enrollment  , and AF found on the electrocardiogram ( ECG ) at enrollment . We assessed outcomes and treatment response to spironolactone in all groups , and the association between post-r and omization AF and outcomes in patients free of AF at baseline . The primary outcome of the TOPCAT trial was a composite of cardiovascular mortality , aborted cardiac arrest , or heart failure hospitalization . RESULTS A total of 760 patients ( 43 % ) had a history of AF ( 18 % ) or AF on ECG at enrollment ( 25 % ) . The highest adjusted risk was associated with AF at enrollment ( primary outcome , hazard ratio : 1.34 ; 95 % confidence interval : 1.09 to 1.65 ; p = 0.006 ; and an increased early risk of secondary outcomes ) . Neither history of AF nor AF at enrollment modified the beneficial treatment effect of spironolactone . Post-r and omization AF , which occurred in 6.3 % of patients , was not influenced by spironolactone treatment , but was associated with an increased early risk of the primary outcome ( hazard ratio : 2.32 ; 95 % confidence interval : 1.59 to 3.40 ; p < 0.0001 ) and secondary outcomes . CONCLUSIONS AF at enrollment was associated with increased cardiovascular risk in HFpEF patients in the TOPCAT study . Post-r and omization AF , which was associated with an increased risk of morbidity and mortality , was not influenced by spironolactone . ( Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist [ TOPCAT ] ; NCT00094302 )
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 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 ) .