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Catheter ablation of atrial fibrillation in heart failure reduced recurrence and other risks compared with standard medication alone, a trial showed.

The rate of at a mean 26 months of follow-up was 70% with ablation compared with 34% on amiodarone (Cordarone, P<0.001), , director of arrhythmia services at Montefiore Medical Center in New York City, and colleagues found in the AATAC-AF in Heart Failure trial.

And while the study wasn't powered for clinical endpoints, ablation appeared to cut down on hospitalization (31% versus 57% on amiodarone, P<0.001) and all-cause mortality over 2 years (8% versus 18%, P=0.037).

A more extensive ablation appeared to be more effective in reducing risk, with a 78.8% success rate for pulmonary vein isolate with posterior wall and non-pulmonary vein trigger ablations versus 36.4% with pulmonary vein isolation alone (P<0.001).

"In this patient population, isolation of the pulmonary vein alone is insufficient," Di Biase concluded in presenting the findings at a press conference for the late-breaking clinical trial session at the American College of Cardiology meeting in San Diego. "The outcome will not be as good as if you do more."

However, "the numbers are small enough for this subcomparison that you may have some difficulty regarding this as definitive," cautioned panel discussant , a heart failure specialist at Brigham and Women's Hospital in Boston, noting too that there may have been some element of selection to that comparison.

The trial included 203 adults with persistent afib, New York Heart Association class II or III heart failure, and a left ventricular ejection fraction of 40% or less who were randomized to be treated with catheter ablation or amiodarone.

The ablation group all got pulmonary vein isolation. Additional ablation of linear lesions, complex fractionated electrograms, and non-pulmonary vein triggers was advised but done according to the operator's preference for 80 of the ablation-group patients.

Enrollment also required that patients have a dual chamber implantable cardioverter defibrillator or cardiac resynchronization therapy device, which allowed the researchers to capture all arrhythmic episodes.

Even though the cohort included only cardiac device patients, the findings likely generalize to heart failure patients without devices as well, Jarcho suggested.

In the multivariate analysis adjusting for age, gender, diabetes, and hypertension, amiodarone was associated with 2.5-fold higher odds of recurrence than ablation (P<0.001).

A second ablation was allowed during the 3-month blanking period without counting as recurrence.

Not surprisingly, recurrence-free patients had better quality-of-life by Minnesota Living with Heart Failure Questionnaire score, better ejection fraction, and longer 6-minute walk distances (all P<0.001).

Those findings agree with prior ablation studies, showing an improvement in ejection fraction, although the majority of trials have been done in the setting of normal ejection fraction to start with, Di Biase noted.

From the American Heart Association:

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