Home > atrial fibrillation, Electrophysiology > Journal Club 23 April 2014

Journal Club 23 April 2014

Paper

A Randomized Trial to Assess Catheter Ablation Versus Rate Control in the Management of Persistent Atrial Fibrillation in Heart Failure

Presenter

PM

Summary

Objectives

This study sought to compare catheter ablation with rate control for persistent atrial fibrillation (AF) in heart fail- ure (HF).
Background The optimal therapy for AF in HF is unclear. Drug-based rhythm control has not proved clinically beneficial. Cath-
eter 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 ventric- ular ejection fraction (EF) Յ35%, 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 Ϯ 9 years, EF 24 Ϯ 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 ϩ3.07 ml/kg/min, 95% confidence interval: 0.56 to 5.59, p ϭ 0.018). The change was not evident at 3 months (ϩ0.79 ml/kg/min, 95% confidence interval: Ϫ1.01 to 2.60, p ϭ 0.38). Ablation improved Minnesota score (p ϭ 0.019) and B-type natriuretic peptide (p ϭ 0.045) and showed nonsignificant trends toward improved 6-min walk distance (p ϭ 0.095) and EF (p ϭ 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 ef- fects develop over 12 months, consistent with progressive amelioration of the HF syndrome.

Supplementary Material

The editorial is here.

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