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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...

Pulmonary-vein isolation was superior to atrioventricular-node ablation with biventricular pacing in patients with heart failure who had drug-refractory atrial fibrillation. (ClinicalTrials.gov number, NCT00599976.)

Background-Monitoring implantable cardiac device function and patient condition is important. The Lumos-T SafelyReduces Routine Office Device Follow-Up (TRUST) trial tested the hypothesis that remote home monitoring with automatic daily surveillance (HM) is safe and effective for implantable cardioverter-defibrillator follow-up for 1 year and enables rapid physician evaluation of significant events. Methods and Results-In total, 1339 patients were randomized 2:1 to HM or conventional follow-up. Follow-up checks occurred at 3, 6, 9, 12, and 15 months after implantation. HM was used before office visits at 3 and 15 months in the HM group. At 6, 9, and 12 months, HM only was used but was followed by office visits if necessary. Conventional patients were evaluated with office visits only. Scheduled office visits and unscheduled evaluations, incidence of morbidity, and time elapsed from first event occurrence in each patient to physician evaluation were tracked for each group. HM and conventional patients were similar (age, 63.3Ϯ12. 2 However, clinical practice is inconsistent. Follow-up schedules vary according to facility, physician preference, and available resources. Expert consensus advocates 3-to 6-month clinic checks with increased frequency in response to product advisories and recalls. 2 Efficacy of this schedule with regard to patient safety, adherence, incidence of unscheduled encounters, and rate of problem detection remains untested. A major limitation of conventional follow-up, regardless of frequency, is the absence of monitoring between hospital interrogations, which accounts for the majority of the time. Hence, recorded data remain concealed for extended periods. This is important if clinical intervention based on these data would preempt patient morbidity/mortality, as may be the case with product advisories. Increased frequency of evaluation of a large patient population with a low incidence of problems challenges both patient compliance and clinic follow-up capacity. A mechanism for performing continuous surveillance and rapid problem identification notification, without overburdening device clinics, is desirable. Editorial see p 319 Clinical Perspective on p 332Currently available remote technologies differ operationally. Some rely on patient-initiated communication on a scheduled calendar basis. 5-7 These risk missing interim asymptomatic problems. In contrast, remote home monitoring (HM) performs daily self-checks with a fully automatic transmission path independent of patient or physician interaction. 8 -10 Stored ICD data are relayed every 24 hours and delivered as trend data for Web site review. Critical events (eg, arrhythmia onset or compromised device integrity) are transmitted separately and flagged for attention. Technical reliability (preservation of data integrity during transmission and early notification ability) of HM and feasibility for remote follow-up have been demonstrated in preliminary evaluations. 8,9 This system offers the advantages of providing nearly continuous arrhyt...

The combination of an open irrigation ablation catheter and periprocedural therapeutic anticoagulation with warfarin may reduce the risk of periprocedural stroke without increasing the risk of pericardial effusion or other bleeding complications.

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Although the AF recurrence rate after initial PVI in impaired EF patients was higher than in normal EF subjects, nearly three-fourths of patients with impaired EF remained AF-free. Although our sample size was nonrandomized, our results suggest PVI may be a feasible therapeutic option in AF patients with impaired EF. Randomized studies with more patients and longer follow-up are warranted.

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