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Updated: Jan 3, 2026
Catheter Ablation in Combination With Left Atrial Appendage Closure for Atrial Fibrillation
Published on: February 26, 2013
Catheter Ablation Versus Best Medical Therapy in Patients With Persistent Atrial Fibrillation and Congestive Heart
Karl-Heinz Kuck1, Béla Merkely2, Ralf Zahn3
1Department of Cardiology, Asklepios Klinik St Georg, Hamburg, Germany (K.-H.K., R.R.T.).
Insights
Catheter ablation did not improve left ventricular ejection fraction (LVEF) in patients with persistent atrial fibrillation and heart failure compared to best medical therapy. The AMICA trial found no significant benefit for ablation in this patient group.
Area of Science:
- Cardiology
- Electrophysiology
- Heart Failure Management
Background:
- Optimal treatment for persistent atrial fibrillation (AF) and heart failure (HF) with reduced left ventricular ejection fraction (LVEF) remains controversial.
- Patients with persistent AF, LVEF ≤35%, and an indication for defibrillator therapy were studied.
Purpose of the Study:
- To compare the efficacy of catheter ablation versus best medical therapy (BMT) in improving LVEF in patients with persistent AF and HF.
- To evaluate secondary endpoints including functional capacity and quality of life.
Main Methods:
- Randomized trial comparing catheter ablation (pulmonary vein isolation) to BMT in 140 patients with persistent AF and HF.
- Primary endpoint: absolute increase in LVEF at 1 year. Secondary endpoints: 6-minute walk test, quality-of-life, NT-proBNP, and AF burden.
Main Results:
- No significant difference in LVEF increase between ablation (8.8%) and BMT (7.3%) groups at 1 year (P=0.36).
- Higher rates of sinus rhythm (73.5% vs 50%) and lower AF burden (72% vs 44%) in the ablation group.
- No significant difference in secondary outcome measures between groups.
Conclusions:
- Catheter ablation showed no benefit over BMT for improving LVEF in patients with persistent AF and advanced HF.
- The limited benefit of ablation may be related to the severity of heart failure at baseline.
Background:
Optimal treatment of patients with persistent atrial fibrillation (AF) and heart failure (HF) with reduced left ventricular ejection fraction (LVEF) and an indication for internal defibrillator therapy is controversial.
Methods:
Patients with persistent/longstanding persistent AF and LVEF ≤35% were randomly allocated to catheter ablation of AF or best medical therapy (BMT). The primary study end point was the absolute increase in LVEF from baseline at 1 year. Secondary end points included 6-minute walk test, quality-of-life, and NT-proBNP (N-terminal pro-brain natriuretic peptide). Pulmonary vein isolation was the primary ablation approach; BMT comprised rate or rhythm control. All patients were discharged after index hospitalization with a cardioverter-defibrillator or cardiac resynchronization therapy defibrillator implanted. The study was terminated early for futility.
Results:
Of 140 patients (65±8 years, 126 [90%] men) available for the end point analysis, 68 and 72 patients were assigned to ablation and BMT, respectively. At 1 year, LVEF had increased in ablation patients by 8.8% (95% CI, 5.8%-11.9%) and in BMT patients by 7.3% (4.3%-10.3%; P=0.36). Sinus rhythm was recorded on 12-lead electrocardiograms at 1 year in 61/83 ablation patients (73.5%) and 42/84 BMT patients (50%). Device-recorded AF burden at 1 year was 0% or maximally 5% of the time in 28/39 ablation patients (72%) and 16/36 BMT patients (44%). There was no difference in secondary end point outcome between ablation patients and BMT patients.
Conclusions:
The AMICA trial (Atrial Fibrillation Management in Congestive Heart Failure With Ablation) did not reveal any benefit of catheter ablation in patients with AF and advanced HF. This was mainly because of the fact that at 1 year, LVEF increased in ablation patients to a similar extent as in BMT patients. The effect of catheter ablation of AF in patients with HF may be affected by the extent of HF at baseline, with a rather limited ablation benefit in patients with seriously advanced HF.
Clinical Trial Registration:
URL: https://www.clinicaltrials.gov. Unique identifier: NCT00652522.
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