Catheter ablation for atrial fibrillation in heart failure patients

Objectives: The objective of the study was to compare rate control versus atrial fibrillation (AF) catheter ablation strategies in patients with AF and heart failure (HF). Background: Rhythm control with antiarrhythmic drugs (AADs) is not superior to rate control in patients with HF and AF, but AF ablation may be more successful at achieving rhythm control than are AADs. However, risks for both ablation and AADs are probably higher and success rates lower in patients with HF. Methods: We conducted a meta-analysis of trials that randomized HF patients (left ventricular ejection fraction [LVEF] <50%) with AF to a rate control or AF catheter ablation strategy and reported changes in LVEF, quality of life, 6-min walk test, or peak oxygen consumption. Study quality and heterogeneity were assessed through the use of Jadad scores and Cochran’s Q statistics, respectively. Mantel-Haenszel relative risks and mean differences were calculated through the use of random effect models. Results: Four trials (N = 224) met inclusion criteria; 82.5% (n = 185) had persistent AF. AF ablation was associated with an increase in LVEF (mean difference, 8.5%; 95% confidence interval [CI]: 6.4% to 10.7%; p < 0.001) compared with rate control. AF ablation was superior in improving quality of life by Minnesota Living With Heart Failure (MLWHF) questionnaire scores (mean difference, –11.9; 95% CI: –17.2 to 6.6; p < 0.001). Peak oxygen consumption and 6-min walk distance increased in AF ablation compared with rate-control patients (mean difference, 3.2; 95% CI: 1.1 to 5.3; p = 0.003; mean difference, 34.8; 95% CI: 2.9 to 66.7; p = 0.03, respectively). In the persistent AF subgroup, LVEF and MLWHF were significantly improved with AF ablation. Major adverse event rates (risk ratio: 1.3; 95% CI: 0.4 to 3.9; p = 0.64) were not significantly different. No significant heterogeneity was evident. Conclusions: In patients with HF and AF, AF catheter ablation is superior to rate control in improving LVEF, quality of life, and functional capacity. Before accepting a rate-control strategy in HF patients with persistent or drug-refractory AF, consideration should be given to AF ablation