Randomized Clinical Trials of

Catheter Ablation of Atrial

Fibrillation in Congestive Heart
Failure
Knowns and Unmet Needs
Maria Terricabras, MDa, Jonathan P. Piccini Sr, MD, MHS, FHRSb, Atul Verma, MD, FRCPC, FHRSa

Cardiol Clin 37 (2019) 167–176 ;https://doi.org/10.1016/j.ccl.2019.01

Introduction
• Atrial fibrillation (AF) increases morbidity and mortality in patients
with heart failure and reduced ejection fraction (HFrEF).
• Anti arrhythmic medications used to treat AF are contraindicated in
the presence of structural heart disease and HFrEF, and other
medications, like beta-blockers, may not be as effective in HFrEF
patients with AF
• Optimal treatment of AF in heart failure remains a major challenge for
clinicians.
Prior studies of antiarrhythmic drug
AF-CHF trial DIAMOND CHF trial
• Hypothesis: maintaining sinus rhythm with a • Subject: patients with CHF NYHA III-IV and
rhythm control strategy would change the LVEF <35%
natural history of CHF-AF conditions in • Treatment:bplacebo vs class III ADD dofetilide
patients with HFrEF and prove superior to a
strategy of rate control alone. • Result:
• Result: - dofetilide was associated with a lower risk of
HF hospitalization
- the rhythm control arm (predominantly
amiodarone) failed to improve all-cause - no evidence of improved survival compared
survival compared with rate control with placebo
- rhythm control was associated with an
increased risk of all-cause hospitalization.

As a results:
- most international guidelines recommend rate control as the first-line therapy for AF in patients with HFrEF
- rhythm control only for those patients with ongoing symptoms secondary to AF despite rate control
Why the AAD treatment may not
improve outcomes in these studies?
1. Limited efficacy of AAD treatment to maintain sinus rhythm (only
+28% in DIAMOND CHF and +32% in AF-CHF)
2. The beneficial effects of maintaining sinus rhythm with AADs are
abrogated by the occurrence of adverse events, and in the case of
amiodarone, end organ toxicities.
 Catheter Ablation
• Alternative to AAD for maintaining sinus rhythm in patients with paroxysmal and
persistent forms of AF
• Superior to AAD for achieving sinus rhythm both for patients who are refractory
to drugs or for first-line therapy (most trials not focused on on patients with
ventricular dysfunction.
• Safe procedure with a low rate of major complications
• Improvement in postablation ejection fraction (EF), quality of life (QoL), and
functional capacity in the AF and HFrEF population

QUESTIONS: The efficacy and safety of this procedure in patients with HFrEF

In this article, the authors review the available randomized data available to compare CA to medical therapy
alone in the AF and HF population as well as the unmet needs in this challenging population.
UNMET NEEDS FOR ATRIAL FIBRILLATION ABLATION IN
HEART FAILURE PATIENTS: WHAT CAN WE DO?

1. Whether these results of ablation will be durable.

2. Who is the optimal patient for receiving AF ablation in the setting of
HF? -- the best candidates for CA? parameters before the thought of
ablation is abandoned? Do patients need to fail AAD treatment first,
or can ablation be offered as first-line therapy for selected patients.
3. The optimal ablation strategy in patients with AF and HF  PVI is
the only strategy that has been proven to be of benefit for AF
ablation.
4. New safer technique of ablation with minimal complication
 Algorithm for management of AF in HF
1. Patients should already be optimized with HF medical
therapy, oral anticoagulation, AF rate control, and if
necessary, ICD and/or CRT therapy before ablation is
considered
2. Patients must be carefully selected to avoid patients with
high frailty in whom ablation may cause more procedural
harm than long-term good.
3. A trial of sinus rhythm by cardioversion and/or drugs should
be attempted  to determine if there is improvement in the
patient’s symptoms and functional status.
4. Patients who are recurrently hospitalized because of
episodes of AF and in whom AF is thought to be the primary
cause of cardiomyopathy (“rate-related”) may be particularly
suited for ablation.
5. Patients, operators, and referring physicians must
understand that more than one procedure may be required
in order to maintain sinus rhythm (with or without ongoing
AAD therapy) and that the benefit may not be real- ized for
months

Fig. 1. Algorithm for management of AF in HF. a Multiple co-morbidities, advanced

age, LA diameter >55–60 mm, very low EF. AV, atrioventricular; BIV, biventricular.
Summary
• Randomized clinical trials have reported a significant improvement in
symptoms, QoL, and EF in patients with HFrEF who underwent a CA
for paroxysmal or persistent AF
• Need of further studies with endpoints of mortality and
hospitalization considering the lower success rate and higher
incidence of adverse events reported in previous studies