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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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Ablation for Atrial Fibrillation in Heart Failure with Reduced Ejection Fraction
Liang, J. J., & Callans, D. J. (2018) · Cardiac failure review · doi:10.15420/cfr.2018:3:1 · Cited by 23
“Beta-blockers have long been considered the cornerstone of HF therapy in patients with reduced LVEF.”
BackgroundInfluentialUnni, R. R., Prager, R. T., Odabashian, R., Zhang, J. J., Hing, N. N. F., Nery, P. B., Pi, L., Aldawood, W., Sadek, M. M., Redpath, C. J., et al. (2022) · CJC Open · doi:10.1016/j.cjco.2022.02.001 · Cited by 21
“Multiple randomized studies have shown that catheter ablation for AF improves QoL, reduces cardiovascular hospitalization and mortality, and is superior to antiarrhythmic therapy for maintaining sinus rhythm in subjects with paroxysmal AF (PAF).(11-22) More recently, the Early Treatment of Atrial Fibrillation for Stro…”
BackgroundManolis, A. S., Manolis, T. A., Manolis, A. S., & Melita, H. (2022) · Heart Failure Reviews · doi:10.1007/s10741-022-10221-1 · Cited by 21
Romero, J. E., Gabr, M., Alviz, I., Briceno, D. F., Díaz, J. C., Rodríguez, D., Patel, K., Polanco, D., Trivedi, C. G., Mohanty, S., et al. (2022) · Journal of Cardiovascular Electrophysiology · doi:10.1111/jce.15622 · Cited by 21
Shiraishi, Y., Kohsaka, S., Ikemura, N., Kimura, T., Katsumata, Y., Tanimoto, K., Suzuki, M., Ueda, I., Fukuda, K., & Takatsuki, S. (2022) · EP Europace · doi:10.1093/europace/euac108 · Cited by 21
Magnocavallo, M., Parlavecchio, A., Vetta, G., Gianni, C., Polselli, M., Vuono, F. D., Pannone, L., Mohanty, S., Cauti, F. M., Caminiti, R., et al. (2022) · Journal of Clinical Medicine · doi:10.3390/jcm11195530 · Cited by 21
“, 2011 [23] ARC-HF, 2013 [21] CAMTAF, 2014 [20] AATAC, 2016 [19] CAMERAMRI, 2017 [24] CASTLE-AF, 2018 [18] AMICA, 2019 [13] CAMERA LATE OUTCOMES, 2020 [22] CABANA, 2021 [17] RAFT-AF, 2022 [14]”
BackgroundMethodResultInfluentialFiala, M., Bulková, V., Škňouřil, L., Nevřalová, R., Toman, O., Januška, J., Špinar, J., & Wichterle, D. (2015) · Heart Rhythm · doi:10.1016/j.hrthm.2015.01.004 · Cited by 21
Zhang, Z., Zheng, Y., He, W., Wei, J., Li, P., Zhong, G., & Jiang, Z. (2024) · ESC Heart Failure · doi:10.1002/ehf2.14814 · Cited by 20
Zhang, Z., Li, L., Zhao, H., Zhou, L., Zhang, Z., Xiong, Y., & Yao, Y. (2023) · BMC Medical Genomics · doi:10.1186/s12920-023-01606-8 · Cited by 21
“Some studies suggested that catheter ablation was associated with improvement in ejection fraction(EF), B-type natriuretic peptide(BNP) level, and quality of life [29, 30].”
BackgroundUremic Toxins and Atrial Fibrillation: Mechanisms and Therapeutic Implications
Yamagami, F., Tajiri, K., Yumino, D., & Ieda, M. (2019) · Toxins · doi:10.3390/toxins11100597 · Cited by 20
Dielectric Properties of Ovine Heart at Microwave Frequencies
Ištuk, N., Porter, E., O’Loughlin, D., McDermott, B., Santorelli, A., Abedi, S., Joachimowicz, N., Roussel, H., & O’Halloran, M. (2021) · Diagnostics · doi:10.3390/diagnostics11030531 · Cited by 20
“It is generally a second-line treatment after failure of or intolerance to antiarrhythmic drug therapy [25,27,28] and it has developed from a specialized, experimental procedure into a common treatment to prevent recurrent AF [25,29].”
BackgroundAtrial fibrillation and heart failure- results of the CASTLE-AF trial
Shah, S. R., Moosa, P. G., Fatima, M., Ochani, R. K., Shahnawaz, W., Jangda, M. A., & Shah, S. A. (2018) · Journal of Community Hospital Internal Medicine Perspectives · doi:10.1080/20009666.2018.1495979 · Cited by 20
Sex-Related Differences in Catheter Ablation for Patients With Atrial Fibrillation and Heart Failure
Chibber, T., & Baranchuk, A. M. (2020) · Frontiers in Cardiovascular Medicine · doi:10.3389/fcvm.2020.614031 · Cited by 19
Chew, D. S., Loring, Z., Anand, J., Fudim, M., Lowenstern, A. M., Rymer, J. A., Weimer, K. E. D., Atwater, B. D., DeVore, A. D., Exner, D. V., et al. (2020) · Circulation Cardiovascular Quality and Outcomes · doi:10.1161/circoutcomes.120.007094 · Cited by 20
“56), and (2) a recent large observational study using US administrative data to evaluate AF catheter ablation in a real-world patient cohort with AF and HFrEF (ie, all-cause mortality HR 0.”
BackgroundMethodInfluentialShetty, S. S., & KRUMERMAN, A. K. (2022) · Cardiovascular Diabetology · doi:10.1186/s12933-022-01552-2 · Cited by 20
Atrial Fibrillation and Heart Failure: Cause or Effect?
Luong, C. L., Barnes, M. E., & Tsang, T. S. M. (2014) · Current Heart Failure Reports · doi:10.1007/s11897-014-0229-1 · Cited by 19
Arrhythmias in Structural Heart Disease
Gillespie, H. S., Lin, C. C. H., & Prutkin, J. M. (2014) · Current Cardiology Reports · doi:10.1007/s11886-014-0510-7 · Cited by 18
Shi, R., Norman, M. W., Chen, Z., & Wong, T. (2018) · Future Cardiology · doi:10.2217/fca-2017-0109 · Cited by 19
Proietti, R., Birnie, D. H., Ziegler, P., Wells, G. A., & Verma, A. (2018) · Journal of the American Heart Association · doi:10.1161/jaha.118.010256 · Cited by 19
Okawa, K., Miyoshi, T., Tsukuda, S., Hara, S., Matsuo, N., Nishibe, N., Sogo, M., Okada, T., Nosaka, K., Sakane, K., et al. (2017) · International Journal of Cardiology · doi:10.1016/j.ijcard.2017.06.038 · Cited by 19
Atrial Fibrillation and Congestive Heart Failure
Thihalolipavan, S., & Morin, D. P. (2014) · Heart Failure Clinics · doi:10.1016/j.hfc.2013.12.005 · Cited by 18
Turagam, M. K., Neužil, P., Schmidt, B., Reichlin, T., Neven, K. G. E. J., Metzner, A., Hansen, J., Blaauw, Y., Maury, P., Arentz, T., et al. (2024) · JACC. Clinical electrophysiology · doi:10.1016/j.jacep.2024.05.002 · Cited by 21
Vecchio, N. (2019) · Journal of Atrial Fibrillation · doi:10.4022/jafib.2128 · Cited by 18
Hodges, G. W., Bang, C. N., Torp-Pedersen, C. T., Hansen, M. L., Schjerning, A. M., Hansen, J., Johannessen, A. C., Gislason, G., & Pallisgaard, J. L. (2020) · Journal of Interventional Cardiac Electrophysiology · doi:10.1007/s10840-020-00741-x · Cited by 18
Fiala, M., Bulková, V., Škňouřil, L., Nevřalová, R., Toman, O., Januška, J., Špinar, J., & Wichterle, D. (2016) · EP Europace · doi:10.1093/europace/euw282 · Cited by 18
What clinical trials of ablation for atrial fibrillation tell us – and what they do not
Amuthan, R., & Curtis, A. B. (2021) · Heart Rhythm O2 · doi:10.1016/j.hroo.2021.02.001 · Cited by 17
“Key inclusion Table 5 Clinical trials evaluating ablation in patients with atrial fibrillation and heart failure Study Methods Definition of recurrent atrial arrhythmia Monitoring methods Freedom from recurrence Results (primary outcomes) Khan et al (PABA CHF)47 2008 PVI vs AVN ablation and BIV pacing in symptomatic,…”
BackgroundInfluentialAtrial Fibrillation Ablation: Current Practice and Future Perspectives
Rottner, L., & Metzner, A. (2023) · Journal of Clinical Medicine · doi:10.3390/jcm12247556 · Cited by 17
“As an exception, in selected patients with heart failure and reduced left ventricular fraction (HFrEF), catheter ablation was proven to reduce all-cause mortality and re-hospitalization, and was also associated with significant improvement of left ventricular function [15,19,20].”
BackgroundTereshchenko, S. N., Жиров, И. В., Романова, Н. В., Osmolovskaya, Y. F., & Sp, G. (2015) · Rational Pharmacotherapy in Cardiology · doi:10.20996/1819-6446-2015-11-6-577-581 · Cited by 17
Agasthi, P., Lee, J. Z., Amin, M., Al‐Saffar, F., Goel, V., Tseng, A. S., Almader‐Douglas, D., Killu, A. M., Deshmukh, A. J., Munoz, F. D., et al. (2019) · Journal of Arrhythmia · doi:10.1002/joa3.12146 · Cited by 16
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“Further, the hospitalizations for HF were significantly fewer in the patients with SR and in those with recurrent PAF than in those with recurrent persistent AF after the AF ablation procedure.”
BackgroundInfluentialGuo, J., Song, Z., Wang, S., Yao, D., Yu, H., Fu, M., Chen, M., Jiang, W., Zhang, Y., Wu, S., et al. (2025) · Circulation Arrhythmia and Electrophysiology · doi:10.1161/circep.125.014069 · Cited by 15
Case Selection for Cardiac Resynchronization in Atrial Fibrillation
Cleland, J. G. F., Keshavarzi, F., Pellicori, P., & Dicken, B. (2013) · Heart Failure Clinics · doi:10.1016/j.hfc.2013.07.001 · Cited by 14
Catheter ablation of atrial fibrillation in heart failure with reduced ejection fraction
Malhi, N., Hawkins, N. M., Andrade, J. G., Krahn, A. D., & Deyell, M. W. (2018) · Journal of Cardiovascular Electrophysiology · doi:10.1111/jce.13497 · Cited by 15
Meta-Analysis of Atrial Fibrillation Ablation in Patients with Systolic Heart Failure
Ruzieh, M., Foy, A., Aboujamous, N. M., Moroi, M. K., Naccarelli, G. V., Ghahramani, M., Kanjwal, S., Marine, J. E., & Kanjwal, K. (2019) · Cardiovascular Therapeutics · doi:10.1155/2019/8181657 · Cited by 15
“Outcome assessment, specifically ejection fraction, was blinded in four trials [2, 3, 8, 9].”
BackgroundMethodResultInfluentialKarlsson, L. O., Erixon, H., Ebbers, T., Bolger, A. F., & Carlhäll, C. (2019) · Frontiers in Physiology · doi:10.3389/fphys.2019.00659 · Cited by 15
Jones, D. G., Haldar, S., Jarman, J. W. E., Johar, S., Hussain, W., Markides, V., & Wong, T. (2013) · Circulation Arrhythmia and Electrophysiology · doi:10.1161/circep.113.000390 · Cited by 15
“gov, NCT00878384).(13) All had symptomatic persistent AF, without prior ablation, and left ventricular ejection fraction ≤35%.”
BackgroundChan, C., Lin, Y., Chen, Y., Lu, Y., Chen, S., & Chen, Y. (2019) · International Journal of Molecular Sciences · doi:10.3390/ijms20133224 · Cited by 15
Catheter ablation versus rate control in patients with atrial fibrillation and heart failure
Geng, J., Zhang, Y., Wang, Y., Cao, L., Song, J., Wang, B., Song, W., Ju, L., & Xu, W. (2017) · Medicine · doi:10.1097/md.0000000000009179 · Cited by 15
Kim, M., Lee, J., Cho, H., Cho, J. Y., Choi, J., Hwang, K., Yoo, B., Kang, S., & Choi, D. (2018) · Korean Circulation Journal · doi:10.4070/kcj.2018.0351 · Cited by 14
Takano, N., Amiya, E., Oguri, G., Nakayama, A., Taya, M., Nakajima, T., Morita, H., & Komuro, I. (2019) · IJC Heart & Vasculature · doi:10.1016/j.ijcha.2018.12.014 · Cited by 14
“On the contrary, the development of new therapeutic strategies against AF, including catheter ablation, has clearly improved the symptomatology for each patient [5].”
Background
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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