Optimal Ablation Strategies for Persistent Atrial Fibrillation With Heart Failure: Three-Year Follow-Up of a Prospective Multicenter Randomized Trial

BACKGROUND: Catheter ablation has been shown to improve prognosis in patients with heart failure (HF) and atrial fibrillation (AF); however, the optimal ablation strategy remains undefined. METHODS: In this multicenter, randomized controlled trial, 300 patients with persistent AF and HF, including both HF with reduced ejection fraction (ejection fraction ≤40%) and HF with preserved ejection fraction (ejection fraction >40%, including mid-range ejection fraction [ejection fraction 41% to 50%]), were enrolled and randomized equally to the anatomic-guided ablation, electrogram-guided ablation, and extensive electrogram-anatomic-guided ablation groups, with 100 patients in each group. The coprimary end points were: (1) the composite of cardiovascular death or HF-related hospitalization/urgent visit within 36 months; and (2) maintenance of sinus rhythm at 36 months. Secondary end points included AF burden <1%, New York Heart Association class improvement (≥1 grade), 6-minute walk test change, NT-proBNP (N-terminal pro-B-type natriuretic peptide) reduction, and procedure-related complications. Subgroup analyses were performed for HF with reduced ejection fraction and HF with preserved ejection fraction. RESULTS: =0.039) groups. Consistent improvements were observed for AF burden <1%, New York Heart Association class, 6-minute walk test, and NT-proBNP. Major complications were low and similar across all groups. These trends were consistent in both the HF with reduced ejection fraction and HF with preserved ejection fraction subgroups. CONCLUSIONS: Electrogram-anatomic ablation provides superior long-term rhythm control, reduces cardiovascular events, and improves symptoms in patients with persistent AF and HF, regardless of ejection fraction. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT07153718.