Ablation Versus Amiodarone for Treatment of Persistent Atrial Fibrillation in Patients With Congestive Heart Failure and an Implanted Device

Abstract

T ranscatheter ablation represents a valid treatment option in patients with drug-refractory symptomatic atrial fibrillation (AF). 1 The majority of catheter ablation trials have mainly enrolled patients with preserved left ventricular (LV) systolic function. In these patients, the ablative treatment has been shown to be effective in reducing morbidity, 2-4 improving the quality of life (QoL), [3][4][5][6] and improving functional capacity. 5-7Background-Whether catheter ablation (CA) is superior to amiodarone (AMIO) for the treatment of persistent atrial fibrillation (AF) in patients with heart failure is unknown. Methods and Results-Thiswas an open-label, randomized, parallel-group, multicenter study. Patients with persistent AF, dualchamber implantable cardioverter defibrillator or cardiac resynchronization therapy defibrillator, New York Heart Association II to III, and left ventricular ejection fraction <40% within the past 6 months were randomly assigned (1:1 ratio) to undergo CA for AF (group 1, n=102) or receive AMIO (group 2, n=101). Recurrence of AF was the primary end point. All-cause mortality and unplanned hospitalization were the secondary end points. Patients were followed up for a minimum of 24 months. At the end of follow-up, 71 (70%; 95% confidence interval, 60%-78%) patients in group 1 were recurrence free after an average of 1.4±0.6 procedures in comparison with 34 (34%; 95% confidence interval, 25%-44%) in group 2 (log-rank P<0.001). The success rate of CA in the different centers after a single procedure ranged from 29% to 61%. After adjusting for covariates in the multivariable model, AMIO therapy was found to be significantly more likely to fail (hazard ratio, 2.5; 95% confidence interval, 1.5-4.3; P<0.001) than CA. Over the 2-year follow-up, the unplanned hospitalization rate was (32 [31%] in group 1 and 58 [57%] in group 2; P<0.001), showing 45% relative risk reduction (relative risk, 0.55; 95% confidence interval, 0.39-0.76). A significantly lower mortality was observed in CA (8 [8%] versus AMIO (18 [18%]; P=0.037). Conclusions-This multicenter randomized study shows that CA of AF is superior to AMIO in achieving freedom from AF at long-term follow-up and reducing unplanned hospitalization and mortality in patients with heart failure and persistent AF. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00729911. However, a significant number of patients with AF also have LV systolic dysfunction. AF and heart failure (HF) frequently coexist and are often associated with several common predisposing risk factors such as hypertension, coronary artery disease, structural heart disease (nonischemic, valvular), diabetes mellitus, obesity, and obstructive sleep apnea . 8,9 Importantly, the prevalence of AF increases with HF severity, ranging from 5% in functional class I patients to ≈50% in class IV patients.Also, the prevalence of HF in patients with AF has been estimated at 42%. 8 The combination of HF and AF leads to deleterious hemodynamic and symp...

Staged hybrid procedure in persistent atrial fibrillation: safety, efficacy, and atrial tachyarrhythmia

“…The outcomes of catheter ablation of persistent and long-standing persistent atrial fibrillation have not been satisfactory (2)(3)(4)(5)(6). However, the stand-alone Coxmaze procedure of persistent atrial fibrillation without concomitant cardiac surgery is not recommended because of the risk of complications, including mortality (7,8).…”

Atrial Fibrillation in Heart Failure US Ambulatory Cardiology Practices and the Potential for Uptake of Catheter Ablation: An National Cardiovascular Data Registry (NCDR ® ) Research to Practice (R2P) Project

“…When compared with the AATAC trial population,10 the PINNACLE AATAC cohort was older (71±11 versus 61±11, y), had more comorbidities (hypertension [82% versus 47%], diabetes mellitus [32% versus 23%], and coronary artery disease [79% versus 64%]), and was on greater medical therapy, including angiotensin‐converting enzyme inhibitor (100% versus 90%) and beta‐blocker (100% versus 78%) 10. Male predominance and EF were comparable among all groups.…”

Atrial Fibrillation in Patients with Cardiac Resynchronization Therapy: Therapeutic Options

“…Despite its potency, the recurrence rate of AF in heart failure patients with implanted defibrillators can be such great as 64% over the 2-year follow-up. 31 Dofetilide is more effective than placebo in converting to and maintaing sinus rhythm in patients with AF and heart failure (hazard ratio for the recurrence of AF 0.35, p < 0.001).…”