Table 1.

Randomized clinical trials of catheter ablation for atrial fibrillation in patients with chronic heart failure (ranked by severity of heart failure, least to most severe)

	Patients studied	Effect on LA and LV function	Effect on exercise tolerance and quality-of-life	Effect on morbidity and mortality	Limitations of evidence
CAMERA-MRI48	n = 66, EF ≈33%, BNP ≈260 pg/mL, most with long-standing AF	Increase in EF by MRI if minimal pre-existing fibrosis; decrease in LA volume after 6 months	No benefit on exercise tolerance or quality-of-life, despite lack of blinding	No meaningful data on clinical events	Levels of exercise tolerance and natriuretic peptides inconsistent with meaningful heart failure
ARC-HF49	n = 52, EF ≈24%, BNP ≈350 pg/mL, most with long-standing AF	No significant increase in radionuclide EF; decrease in LA (but not right atrial) area after 1 year	Increase in exercise tolerance and quality-of-life, but lack of blinding	No meaningful data on clinical events	—
CASTLE-AF50	n = 397, EF ≈30%, no baseline data on BNP; long-standing AF in only 30%	Reported increase in EF assessed by echocardiography; no data on LA function	Reported increase in exercise tolerance, but lack of blinding; no measures of quality-of-life	Reduced risk of death and of hospitalization for heart failure, but comparator group treated with membrane-active drugs	20% of randomized patients not in primary analysis (more in ablation group); baseline imbalances at randomization (medical group had more severe disease)
AATAC51	n = 203, EF ≈30%, BNP not reported, mean AF duration <1 year	Reported increase in EF assessed by echocardiography; no data on LA function	Increase in exercise tolerance and quality-of-life, but lack of blinding	Numerically fewer deaths in ablation group; but comparator group treated with amiodarone	No data on heart failure hospitalizations; sparse data on mortality
CAMTAF52	n = 55, EF ≈32%, BNP ≈500 pg/mL, most with long-standing AF	Reported increase in EF assessed by echocardiography; no data on LA function	Increase in exercise tolerance and quality-of-life, but lack of blinding	No meaningful data on clinical events	—
MacDonald et al.53	n = 41, EF ≈18%, N-terminal proBNP ≈2200 pg/mL, typically long-standing AF	No increase in EF by MRI; no data on LA function	No benefit on exercise tolerance or quality-of-life, despite lack of blinding	No meaningful data on clinical events	Baseline imbalances (medical group had less severe disease)

AF, atrial fibrillation; BNP, brain natriuretic peptide; EF, ejection fraction; LA, left atrial; MRI, magnetic resonance imaging.