Ablation of atrial fibrillation in patients with heart failure: Reversal of atrial and ventricular remodelling

Introduction: The management of patients with heart failure and atrial fibrillation (AF) is a medical challenge, especially in the case of patients in whom sinus rhythm or rate control cannot be achieved with optimal pharmaceutical treatment. Methods: Thirteen consecutive patients (11 men and 2 women, 35-70 years old, median age 55 +/- 23 years) with heart failure (NYHA I-IV, median ejection fraction 35 +/- 5%, range 25-40%) and symptomatic persistent (10 patients, 76.9%) or permanent (3 patients, 23.1%) AF, underwent circumferential ablation using a system of electroanatomic mapping with contact. Circumferential ablation, encircling the pulmonary veins in pairs, and linear ablation between the left and right superior pulmonary vein and along the mitral isthmus were performed. Follow up included 24-hour Holter monitoring and transthoracic echocardiogram at 1, 3, 6, 9 and 12 months. Results: Eight patients (62%) remained in sinus rhythm at the end of the follow up and had achieved a statistically significant improvement in ejection fraction (from 37.5 +/- 8.75% to 60.0 +/- 3.75%, p=0.011), reduction of left ventricular end-diastolic diameter (from 63.0 +/- 3.25 mm to 56.5 +/- 1.75 mm, p=0.011) and reduction of left atrial diameter (from 49.0 +/- 5.5 mm to 44.5 +/- 4.25 mm, p=0.011). In contrast, patients with relapse of AF had none of the above changes (p>0.05). Prognostic indexes of AF recurrence appeared to be the failure to improve ejection fraction (p=0.003), non-reversal of left ventricular (p=0.002) and left atrial (p=0.006) remodelling, a shorter energy application time (p=0.030) and the presence of coronary artery disease (p=0.035). None of the patients suffered any complication from the procedure. Conclusion: AF ablation in selected patients with heart failure and a low ejection fraction is a relatively effective method of maintaining sinus rhythm, improving left ventricular systolic function and reversing atrial and ventricular remodelling.