AFib and HFrEF: The Great Debates

By Jose Joglar, M.D.
Professor of Internal Medicine

It was my great pleasure to moderate a session in which two debates took place on the optimal therapies for patients with atrial fibrillation and heart failure with reduced ejec­tion fraction. During the first debate, Dr. Richard Schilling from Queen Mary University of London and Dr. Nassir Marrouche from the University of Utah discussed whether all patients with AFib and reduced ejection fraction should be offered ablation, in view of recent landmark clinical trial results. The consensus was that although catheter ablation of AFib has shown to signifi­cantly improve outcomes in this population, and despite the fact that with modern technology the procedure is much safer and less time consuming, a number of patients with very advanced disease, including those with extensive fibrosis or severe left atrial dilation, were less likely to benefit.

With that in mind, Dr. Maurizio Gasparini from the Humanitas Research Hospital in Milan, Italy, and Dr. Prashanthan Sanders from the Univer­sity of Adelaide, Australia, debated whether patients with permanent AFib who have failed to achieve restoration of normal sinus rhythm should undergo atrioventricular node ablation with implantation of a cardiac resynchronization-capable device. The consensus was that patients who benefit most from atrioventricular node ablation were those who already have an indica­tion for cardiac resynchronization therapy but in whom the percentage of pacing was limited by AFib. In contrast, in patients who have a narrow QRS the data supporting this approach were less robust. The discussants agreed that a potential strategy is to offer AFib ablation, and if that fails or the patient is not a candidate, the next step is ablation of the atrioventricular node with cardiac resynchronization therapy, although more data are needed.