title: Catheter Ablation for Atrial Fibrillation in Heart Failure Patients: A Meta-Analysis of Randomized Controlled Trials.
abstract: BACKGROUND
  Rhythm control with antiarrhythmic drugs (AADs) is not superior to rate control in patients with heart failure (HF) and atrial fibrillation (AF), but AF ablation may be more successful at achieving rhythm control than AADs. However, risks for both ablation and AADs are likely higher and success rates lower in patients with HF.
  
  
  OBJECTIVE
  To compare rate control versus AF catheter ablation strategies in patients with AF and HF.
  
  
  METHODS
  We conducted a meta-analysis of trials which randomized HF patients (LVEF<50%) with AF to a rate control or AF catheter ablation strategy and reported change in LVEF, quality of life, 6-minute walk test, or peak oxygen consumption. Study quality and heterogenity were assessed using Jadad scores and Cochran's Q statistics, respectively. Mantel Haenszel relative risks and mean differences were calculated using random effect models.
  
  
  RESULTS
  Four trials (N=224) met inclusion criteria; 82.5% (n=185) had persistent AF. AF ablation was associated with an increase in LVEF (mean difference 8.5%; 95%CI 6.4,10.7%; P<0.001) compared to rate control. AF ablation was superior in improving quality of life by Minnesota Living with Heart Failure (MLWHF) questionnaire scores (mean difference -11.9; 95%CI -17.1, -6.6; P<0.001). Peak oxygen consumption and 6-minute walk distance increased in AF ablation compared to rate control patients (mean difference 3.2; 95%CI 1.1,5.2; P=0.003; mean difference 34.8; 95%CI 2.9, 66.7; P = 0.03, respectively). In the persistent AF subgroup LVEF and MLWHF were significantly improved with AF ablation. Major adverse event rates (RR 1.3; 95% CI, 0.4, 3.9; p=0.64) were not significantly different. No significant heterogeneity was evident.
  
  
  CONCLUSIONS
  In patients with HF and AF, AF catheter ablation is superior to rate control in improving LVEF, quality of life and functional capacity. Prior to accepting a rate control strategy in HF patients with persistent or drug refractory AF, consideration should be given to AF ablation.
authors.affiliation: The Department of Cardiovascular Medicine, Heart & Vascular Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: Shadi
authors.initials: S
authors.lastname: Al Halabi
authors.affiliation: The Department of Cardiovascular Medicine, Heart & Vascular Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: Mohammed
authors.initials: M
authors.lastname: Qintar
authors.affiliation: The Department of Cardiovascular Medicine, Heart & Vascular Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: Ayman
authors.initials: A
authors.lastname: Hussein
authors.affiliation: The Department of Cardiology, University of Minnesota, Minneapolis, MN.
authors.forename: M Chadi
authors.initials: MC
authors.lastname: Alraies
authors.affiliation: Royal Brompton and Harefield National Health Service Foundation Trust, London, United Kingdom ; National Heart and Lung Institute, Imperial College London, London, United Kingdom.
authors.forename: David G
authors.initials: DG
authors.lastname: Jones
authors.affiliation: Royal Brompton and Harefield National Health Service Foundation Trust, London, United Kingdom ; National Heart and Lung Institute, Imperial College London, London, United Kingdom.
authors.forename: Tom
authors.initials: T
authors.lastname: Wong
authors.affiliation: Changi, Glasgow, Scotland, United Kingdom.
authors.forename: Michael R
authors.initials: MR
authors.lastname: MacDonald
authors.affiliation: Golden Jubilee National Hospital, Glasgow, Scotland, United Kingdom.
authors.forename: Mark C
authors.initials: MC
authors.lastname: Petrie
authors.affiliation: The Department of Cardiovascular Medicine, Heart & Vascular Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: Daniel
authors.initials: D
authors.lastname: Cantillon
authors.affiliation: The Department of Cardiovascular Medicine, Heart & Vascular Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: Khaldoun G
authors.initials: KG
authors.lastname: Tarakji
authors.affiliation: The Department of Cardiovascular Medicine, Heart & Vascular Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: Mohamed
authors.initials: M
authors.lastname: Kanj
authors.affiliation: The Department of Cardiovascular Medicine, Heart & Vascular Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: Mandeep
authors.initials: M
authors.lastname: Bhargava
authors.affiliation: The Department of Cardiovascular Medicine, Heart & Vascular Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: Niraj
authors.initials: N
authors.lastname: Varma
authors.affiliation: The Department of Cardiovascular Medicine, Heart & Vascular Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: Bryan
authors.initials: B
authors.lastname: Baranowski
authors.affiliation: The Department of Cardiovascular Medicine, Heart & Vascular Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: Bruce L
authors.initials: BL
authors.lastname: Wilkoff
authors.affiliation: The Department of Cardiovascular Medicine, Heart & Vascular Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: Oussama
authors.initials: O
authors.lastname: Wazni
authors.affiliation: The Department of Cardiovascular Medicine, Heart & Vascular Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: Thomas
authors.initials: T
authors.lastname: Callahan
authors.affiliation: The Department of Cardiovascular Medicine, Heart & Vascular Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: Walid
authors.initials: W
authors.lastname: Saliba
authors.affiliation: The Department of Cardiovascular Medicine, Heart & Vascular Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: Mina K
authors.initials: MK
authors.lastname: Chung
keywords: Atrial fibrillation; catheter ablation; heart failure; pulmonary vein isolation