title: A randomized trial to assess catheter ablation versus rate control in the management of persistent atrial fibrillation in heart failure.
abstract: OBJECTIVE
  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).
authors.affiliation: Royal Brompton and Harefield National Health Service Foundation Trust, London, United Kingdom.
authors.forename: David G
authors.initials: DG
authors.lastname: Jones
authors.forename: Shouvik K
authors.initials: SK
authors.lastname: Haldar
authors.forename: Wajid
authors.initials: W
authors.lastname: Hussain
authors.forename: Rakesh
authors.initials: R
authors.lastname: Sharma
authors.forename: Darrel P
authors.initials: DP
authors.lastname: Francis
authors.forename: Shelley L
authors.initials: SL
authors.lastname: Rahman-Haley
authors.forename: Theresa A
authors.initials: TA
authors.lastname: McDonagh
authors.forename: S Richard
authors.initials: SR
authors.lastname: Underwood
authors.forename: Vias
authors.initials: V
authors.lastname: Markides
authors.forename: Tom
authors.initials: T
authors.lastname: Wong
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001281:Atrial Fibrillation / Q000150:complications / Q000503:physiopathology / Q000601:surgery*; D017115:Catheter Ablation / Q000379:methods*; D004311:Double-Blind Method; D004562:Electrocardiography; D005260:Female; D005500:Follow-Up Studies; D006329:Heart Conduction System / Q000503:physiopathology / Q000601:surgery*; D006333:Heart Failure / Q000150:complications* / Q000503:physiopathology; D006339:Heart Rate / Q000502:physiology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D011788:Quality of Life; D016896:Treatment Outcome; D016277:Ventricular Function, Left; D055815:Young Adult