Catheter ablation for atrial fibrillation in congestive heart failure: consider the upside, consider the downside

This editorial refers to ‘Catheter ablation of atrial fibrillation in patients with heart failure: impact of maintaining sinus rhythm on heart failure status and long-term rates of stroke and death’ by W. Ullah et al. , 2016;18(5):679–686. When patients present with deteriorating heart failure (HF) symptoms associated with atrial fibrillation (AF) development, there is understandably considerable clinical momentum to deal definitively with the arrhythmia. The adverse impact of AF on HF symptoms and outcomes including mortality has been extensively documented. However, whether this trend can be successfully reversed by rhythm management has not yet been clearly established. Definitive evidence that return of sinus rhythm results in improved outcomes including stroke risk and mortality has been lacking. Indeed, a randomized study of pharmacologic rhythm control vs. rate control demonstrated no benefit, possibly in part due to relative drug inefficacy and in part to pro-arrhythmia.1 A number of small randomized studies with 6- to 12-month follow-up have shown that compared with a medical rate control strategy, catheter ablation of AF in HF patients results in improved NYHA class2 and increase in ejection fraction.3 However, the latter finding has not been universal,4 and the studies were too small to consider stroke or mortality outcomes.5 Further complicating this picture is the recent STAR AF (Substrate and Trigger Ablation for Reduction of Atrial Fibrillation) 2 study6 finding that there is no proven ablative approach to substrate management in persistent AF. Yet pulmonary vein antral isolation alone for persistent …