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A Randomized Trial to Assess Catheter Ablation Versus Rate Control in the Management of Persistent Atrial Fibrillation in Heart Failure
Open accessAbstract
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 clinically beneficial. Catheter ablation improves cardiac function in patients with HF, but impact on physiological performance has not been formally evaluated in a randomized trial.Methods In a randomized, 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 randomized, 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 randomized 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 Randomised Trial to Assess Catheter Ablation Versus Rate Control in the Management of Persistent Atrial Fibrillation in Chronic Heart Failure; NCT00878384).
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“For patients who develop HFrEF as a result of rapid AF (tachycardiomyopathy), a rhythm control strategy is preferred, based on several relatively small patient cohorts and trials reporting improved LV function after restoration of sinus rhythm.”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [185]
In the citing paper
“Catheter ablation may be a useful method to restore LV function and quality of life in AF patients with HFrEF, 185,[226][227][228] but further data are needed.”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [185]
In the citing paper
“In such patients, catheter ablation is more effective than antiarrhythmic drug therapy.185,586,713,[717][718][719][720]”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [185]
In the citing paper
“Catheter ablation of AF is effective in restoring and maintaining sinus rhythm in patients with symptomatic paroxysmal, persistent, and probably long-standing persistent AF -in general as second-line treatment after failure of or intolerance to antiarrhythmic drug therapy.”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [185]
In the citing paper
“Fewer data are available reporting the effectiveness and safety of catheter ablation in patients with persistent or long-standing persistent AF, but all point to lower recurrence rates after catheter ablation compared to antiarrhythmic drug therapy with or without cardioversion.185,717,[723][724][725][726]1039”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [185]
In the citing paper
“Fewer data are available reporting the effectiveness and safety of catheter ablation in patients with persistent or long-standing persistent AF, but all point to lower recurrence rates after catheter ablation compared to antiarrhythmic drug therapy with or without cardioversion.185,717,[723][724][725][726]1039”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [185]
In the citing paper
“Several smaller trials suggest improved LV function after catheter ablation in HFrEF patients 185, 226-228, 778, 779”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [185]
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MethodResultAblation Versus Drug Therapy for Atrial Fibrillation in Heart Failure
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“Several randomised studies comparing catheter ablation for AF and medical rate control have demonstrated significant improvements in LVEF, NYHA functional class symptoms and reductions in BNP with catheter ablation [403,404].”
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“…al 2009 RFA 35 63 57 100 63 46 55 46/54 44 20 Warfarin d/c 6 mo post-ablation MT 35 65 65 100 69 54 53 37/63 45 20 Warfarin throughout study period Jones et al 2013 RFA 26 64 81 50 38 MT 26 62 92 22 45 29 0/100 46 37 Krittayaphong et al 2003 RFA 15 55 73 7 13 64 73/27 39 Warfarin MT 15 49 53 20…”
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BackgroundMethodGopinathannair, R., Chen, L. Y., Chung, M. K., Cornwell, W. K., Furie, K. L., Lakkireddy, D. R., Marrouche, N. F., Natale, A., Olshansky, B., & Joglar, J. A. (2021) · Circulation Arrhythmia and Electrophysiology · doi:10.1161/hae.0000000000000078 · Cited by 187
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Catheter Ablation of Atrial Fibrillation Using Zero‐Fluoroscopy Technique: A Randomized Trial
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Tachycardia mediated cardiomyopathy: Pathophysiology, mechanisms, clinical features and management
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Catheter Ablation of Atrial Fibrillation in Patients With Heart Failure
Turagam, M. K., Garg, J., Whang, W., Sartori, S., Koruth, J. S., Miller, M. A., Langan, N., Sofi, A. A., Gomes, A., Choudry, S., et al. (2018) · Annals of Internal Medicine · doi:10.7326/m18-0992 · Cited by 133
JCS/JHRS 2020 Guideline on Pharmacotherapy of Cardiac Arrhythmias
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Treatment of Patients With Atrial Fibrillation and Heart Failure With Reduced Ejection Fraction
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Arnar, D. O., Mairesse, G. H., Boriani, G., Calkins, H. G., Chin, A., Coats, A. J. S., Deharo, J., Svendsen, J. H., Heidbüchel, H., Isa, R., et al. (2019) · EP Europace · doi:10.1093/europace/euz046 · Cited by 127
Atrial Fibrillation and Heart Failure — Cause or Effect?
Prabhu, S., Voskoboinik, A., Kaye, D. M., & Kistler, P. M. (2017) · Heart Lung and Circulation · doi:10.1016/j.hlc.2017.05.117 · Cited by 111
Panikker, S., Jarman, J. W. E., Virmani, R., Kutys, R., Haldar, S., Lim, E., Butcher, C., Khan, H. R., Mantziari, L., Nicol, E. D., et al. (2016) · Circulation Arrhythmia and Electrophysiology · doi:10.1161/circep.115.003710 · Cited by 110
Catheter Ablation for Atrial Fibrillation in Heart Failure Patients
Al Halabi, S., Qintar, M., Hussein, A., Alraies, M. C., Jones, D. G., Wong, T., MacDonald, M. R., Petrie, M. C., Cantillon, D., Tarakji, K. G., et al. (2015) · JACC. Clinical electrophysiology · doi:10.1016/j.jacep.2015.02.018 · Cited by 105
“We were able to obtain previously unpublished data on complications and incorporate them into our analysis from 2 RCTs (23,24).”
MethodImpact of SGLT2 Inhibitors on AF Recurrence After Catheter Ablation in Patients With Type 2 Diabetes
Abu-Qaoud, M. R., Kumar, A., Tarun, T., Abraham, S., Ahmad, J., Khadke, S., Husami, R., Kulbak, G., Sahoo, S., Januzzi, J. L., et al. (2023) · JACC. Clinical electrophysiology · doi:10.1016/j.jacep.2023.06.008 · Cited by 104
Atrial fibrillation: comorbidities, lifestyle, and patient factors
Shantsila, E., Choi, E., Lane, D. A., Joung, B., & Lip, G. Y. H. (2024) · The Lancet Regional Health - Europe · doi:10.1016/j.lanepe.2023.100784 · Cited by 108
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Lip, G. Y. H., Heinzel, F. R., Gaïta, F., González‐Juanatey, J. R., Heuzey, J. Y. L., Potpara, T., Svendsen, J. H., Vos, M. A., Anker, S. D., Coats, A. J. S., et al. (2015) · EP Europace · doi:10.1093/europace/euv191 · Cited by 99
“177,180,183 These trial data have confirmed the observational series in terms of freedom from AF, improvement in LVEF, and QoL.”
InfluentialMohanty, S., Santangeli, P., Mohanty, P. K., Biase, L. D., Holcomb, S., Trivedi, C. G., Bai, R., BURKHARDT, D. J., Hongo, R. H., Hao, S. C., et al. (2014) · Journal of Cardiovascular Electrophysiology · doi:10.1111/jce.12467 · Cited by 95
Rhythm Control in Heart Failure Patients With Atrial Fibrillation
Trulock, K. M., Narayan, S. M., & Piccini, J. P. (2014) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2014.06.1169 · Cited by 92
“Specifically, the ARCHF (A Randomised Trial to Assess Catheter Ablation Versus Rate Control in the Management of Persistent Atrial Fibrillation in Chronic Heart Failure) investigators (71) reported a trend toward EF improvement in the ablation group at 12 months, whereas the CAMTAF (Catheter Ablation Versus Medical Tr…”
BackgroundMethodSteinberg, B. A., Li, Z., O'Brien, E. C., Pritchard, J. E., Chew, D. S., Bunch, T. J., Mark, D. B., Nabutovsky, Y., Greiner, M. A., & Piccini, J. P. (2021) · Heart Rhythm · doi:10.1016/j.hrthm.2021.01.021 · Cited by 89
2020 Clinical practice guidelines for Chronic heart failure
Russian Society of Cardiology (2020) · Russian Journal of Cardiology · doi:10.15829/29/1560-4071-2020-4083 · Cited by 88
Cabins, castles, and constant hearts: rhythm control therapy in patients with atrial fibrillation
Willems, S., Meyer, C. G., de Bono, J. P., Brandes, A., Eckardt, L., Elvan, A., Gelder, I. C. V., Goette, A., Gulizia, M. M., Haegeli, L., et al. (2019) · European Heart Journal · doi:10.1093/eurheartj/ehz782 · Cited by 80
Şaylık, F., Çınar, T., Akbulut, T., & Hayıroğlu, M. İ. (2022) · Heart & Lung · doi:10.1016/j.hrtlng.2022.08.012 · Cited by 79
Anić, A., Phlips, T., Brešković, T., Koopman, P., Girouard, S. D., Mediratta, V., Jurišić, Z., Sikiric, I., Lisica, L., & Vijgen, J. M. (2023) · EP Europace · doi:10.1093/europace/euad147 · Cited by 80
Atrial Fibrillation Ablation in Heart Failure With Reduced vs Preserved Ejection Fraction
Oraii, A., McIntyre, W. F., Parkash, R., Kowalik, K., Razeghi, G., Benz, A. P., Belley‐Côté, E. P., Conen, D., Connolly, S. J., TANG, A. S. L., et al. (2024) · JAMA Cardiology · doi:10.1001/jamacardio.2024.0675 · Cited by 91
Atrial Fibrillation–Mediated Cardiomyopathy
Qin, D., MANSOUR, M. C., Ruskin, J. N., & Heist, E. K. (2019) · Circulation Arrhythmia and Electrophysiology · doi:10.1161/circep.119.007809 · Cited by 78
Verhaert, D. V. M., Rocca, H. B., van Veldhuisen, D. J., & Vernooy, K. (2020) · EP Europace · doi:10.1093/europace/euaa368 · Cited by 78
Ganesan, A. N., Nandal, S., Lüker, J., Pathak, R. K., Mahajan, R., Twomey, D., Lau, D. H., & Sanders, P. (2015) · Heart Lung and Circulation · doi:10.1016/j.hlc.2014.09.012 · Cited by 73
“47% of patients) (10, 21-23), pulmonary vein stenosis (six patients, 0.”
BackgroundTzeis, S. E., Gerstenfeld, E. P., Kalman, J. M., Saad, E., Shamloo, A. S., Andrade, J. G., Barbhaiya, C. R., Baykaner, T., Bovéda, S., Calkins, H. G., et al. (2024) · Journal of Arrhythmia · doi:10.1002/joa3.13082 · Cited by 76
Ullah, W., Ling, L., Prabhu, S., Lee, G., Kistler, P. M., Finlay, M., Earley, M. J., Sporton, S. C., Bashir, Y., Betts, T. R., et al. (2016) · EP Europace · doi:10.1093/europace/euv440 · Cited by 71
Efficacy and safety of ablation for people with non-paroxysmal atrial fibrillation
Nyong, J., Amit, G., Adler, A. J., Owolabi, O., Perel, P., Prieto‐Merino, D., Lambiase, P. D., Casas, J. P., & Morillo, C. A. (2016) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd012088.pub2 · Cited by 75
Packer, M. (2019) · European Heart Journal · doi:10.1093/eurheartj/ehz284 · Cited by 71
Simader, F. A., Howard, J. P., Ahmad, Y., Saleh, K., Naraen, A., Samways, J., Mohal, J. S., Reddy, R. K., Kaza, N., Keene, D., et al. (2022) · EP Europace · doi:10.1093/europace/euac173 · Cited by 70
“AF ablation has also been shown to improve echocardiographic measures including LVEF and mitral regurgitation.(13,17) Such measures can be prone to bias in open-label trials, which is why we did not include them in this meta-analysis.”
BackgroundCochet, H., SCHERR, D., Zellerhoff, S., Sacher, F., Derval, N., Denis, A., Knecht, S., Komatsu, Y., Montaudon, M., Laurent, F., et al. (2014) · Journal of Cardiovascular Electrophysiology · doi:10.1111/jce.12449 · Cited by 70
Sethi, N. J., Feinberg, J. B., Nielsen, E. E., Safi, S., Gluud, C. N., & Jakobsen, J. C. (2017) · PLoS ONE · doi:10.1371/journal.pone.0186856 · Cited by 75
Saglietto, A., Ponti, R. D., Biase, L. D., Matta, M., Gaïta, F., Romero, J. E., Ferrari, G. M. D., & Anselmino, M. (2020) · Journal of Cardiovascular Electrophysiology · doi:10.1111/jce.14429 · Cited by 67
Bunch, T. J., May, H. T., Bair, T. L., Jacobs, V., Crandall, B. G., Cutler, M. J., Weiss, J. P., Mallender, C. D., Osborn, J. S., Anderson, J. L., et al. (2014) · Journal of Cardiovascular Electrophysiology · doi:10.1111/jce.12602 · Cited by 66
Tzeis, S. E., Gerstenfeld, E. P., Kalman, J. M., Saad, E., Shamloo, A. S., Andrade, J. G., Barbhaiya, C. R., Baykaner, T., Bovéda, S., Calkins, H. G., et al. (2024) · Journal of Interventional Cardiac Electrophysiology · doi:10.1007/s10840-024-01771-5 · Cited by 66
AlTurki, A., Proietti, R., Dawas, A., Alturki, H., Huynh, T. T., & Essebag, V. (2019) · BMC Cardiovascular Disorders · doi:10.1186/s12872-019-0998-2 · Cited by 65
Atrial Fibrillation in Heart Failure: a Therapeutic Challenge of Our Times
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Persistent atrial fibrillation vs paroxysmal atrial fibrillation: differences in management
Margulescu, A. D., & Mont, L. (2017) · Expert Review of Cardiovascular Therapy · doi:10.1080/14779072.2017.1355237 · Cited by 70
“Only three studies have assessed AF ablation (all in persistent AF patients with systolic heart failure) versus rate control [44,45,47].”
BackgroundAblation of Atrial Fibrillation
Link, M. S., Haı̈ssaguerre, M., & Natale, A. (2016) · Circulation · doi:10.1161/circulationaha.116.021727 · Cited by 64
JCS/JHRS 2024 Guideline Focused Update on Management of Cardiac Arrhythmias
Iwasaki, Y., Noda, T., Akao, M., Fujino, T., Hirano, T., Inoue, K., KUSANO, K. F., Nagai, T., Satomi, K., Shinohara, T., et al. (2025) · Circulation Journal · doi:10.1253/circj.cj-24-0073 · Cited by 57
JCS/JHRS 2021 Guideline Focused Update on Non-Pharmacotherapy of Cardiac Arrhythmias
Nogami, A., Kurita, T., KUSANO, K. F., Goya, M., Shoda, M., Tada, H., Naito, S., Yamane, T., Kimura, M., Shiga, T., et al. (2022) · Circulation Journal · doi:10.1253/circj.cj-21-0162 · Cited by 55
Mechanisms and Clinical Significance of Arrhythmia-Induced Cardiomyopathy
Raymond-Paquin, A., Nattel, S., Wakili, R., & Tadros, R. (2018) · Canadian Journal of Cardiology · doi:10.1016/j.cjca.2018.07.475 · Cited by 56
Hohendanner, F., Heinzel, F. R., Blaschke, F., Pieske, B. M., Haverkamp, W., Boldt, H., & Parwani, A. S. (2017) · Heart Failure Reviews · doi:10.1007/s10741-017-9657-9 · Cited by 54
“Other studies like CAMTAF [73], ARC-AF [74], or PABA-CHF [75] provided additional evidence that a catheter ablation-based strategy leads to superior quality of life and LVEF improvement.”
ResultAtrial Fibrillation and Heart Failure: Update 2015
Thihalolipavan, S., & Morin, D. P. (2015) · Progress in Cardiovascular Diseases · doi:10.1016/j.pcad.2015.07.004 · Cited by 54
Khan, S. U., Rahman, H., Talluri, S., & Kaluski, E. (2018) · JACC. Clinical electrophysiology · doi:10.1016/j.jacep.2018.03.003 · Cited by 53
Catheter Ablation for Atrial Fibrillation in Patients With Concurrent Heart Failure
Arora, S., Jaswaney, R., Jani, C., Zuzek, Z., Thakkar, S. J., Patel, H., Patel, M., Patel, N., Tripathi, B., Lahewala, S., et al. (2020) · The American Journal of Cardiology · doi:10.1016/j.amjcard.2020.09.035 · Cited by 53
Nishino, S., Watanabe, N., Ashikaga, K., Morihisa, K., Kuriyama, N., Asada, Y., & Shibata, Y. (2019) · Circulation Cardiovascular Imaging · doi:10.1161/circimaging.119.009317 · Cited by 52
Tsigkas, G., Apostolos, A., Despotopoulos, S., Vasilagkos, G., Kallergis, E. M., Leventopoulos, G., Mplani, V., & Davlouros, P. A. (2021) · Heart Failure Reviews · doi:10.1007/s10741-021-10133-6 · Cited by 53
Atrial fibrillation ablation in heart failure
Richter, S., Biase, L. D., & Hindricks, G. (2018) · European Heart Journal · doi:10.1093/eurheartj/ehy778 · Cited by 51
Metadata
- Authors
- Jones, D. G., Haldar, S. K., Hussain, W., Sharma, R., Francis, D. P., Rahman-Haley, S. L., McDonagh, T. A., Underwood, S. R., Markides, V., & Wong, T.
- Affiliations
- National Health Service (GB)
- Corresponding author
- Wong, Tom
- ORCID
- Venue
- Journal of the American College of Cardiology
- Publisher
- Elsevier BV
- Published
- 2013-05
- Volume
- 61
- Issue
- 18
- Pages
- 1894-1903
- ISSN
- 0735-1097 (ISSN-L)
- OpenAlex
- W2159999579
- Cited by
- 481
- References
- 44
- Citations by year
- 2026: 16 · 2025: 20 · 2024: 41 · 2023: 36 · 2022: 59 · 2021: 45 · 2020: 41 · 2019: 43 · 2018: 49 · 2017: 37 · 2016: 31 · 2015: 23 · 2014: 26 · 2013: 12
- FWCI
- 20.83
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Journal of the American College of Cardiology (publishedVersion)
- PubMed (publishedVersion)
- Funders
- St. Jude Medical
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Arrhythmias and Treatments
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac pacing and defibrillation studies
- Keywords
- persistent atrial fibrillation, heart failure, catheter ablation, rate control, peak oxygen uptake, exercise capacity, left ventricular ejection fraction, brain natriuretic peptide, quality of life, 6-minute walk distance, sinus rhythm maintenance, cardiac rehabilitation, heart failure with reduced ejection fraction, heart failure with preserved ejection fraction
- MeSH terms
- Adolescent, Adult, Aged, Aged, 80 and over, Atrial Fibrillation, Double-Blind Method, Electrocardiography, Female, Follow-Up Studies, Heart Conduction System, Heart Failure, Heart Rate, Humans, Male, Middle Aged, Prospective Studies, Quality of Life, Ventricular Function, Left, Treatment Outcome, Catheter Ablation, Young Adult
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