Atrioventricular Nodal Catheter Ablation in Atrial Fibrillation Complicating Congestive Heart Failure.

The development of atrial fibrillation (AF) during the course of the evolution of heart failure (HF) worsens the clinical outcomes and the prognosis accounting for an enormous economic burden on healthcare. AF is considered to be an independent predictor of morbidity and mortality increasing the risk of death and hospitalization in 76% in HF patients. Despite the good clinical results obtained with conventional pharmacological agents and different new drugs, the optimal medical treatment can fail in the intention to improve symptoms and quality of life of HF patients with severe left ventricular dysfunction and AF with uncontrolled ventricular rate. Therefore, the necessity to utilize cardiac devices to perform cardiac resynchronization therapy (CRT), or the need to use catheter ablation, or both, emerges facing the failure of optimal medical treatment in order to achieve hemodynamic improvement. Some of these AF patients will require atrio-ventricular nodal (AVN) catheter ablation in order to restore 100% CRT functionality and improvements in clinical outcomes. It is hard to imagine that the deliberate destruction of a natural and normally functional specialized tissue of the main conduction system of the heart would do any good. However, in the presence of AF with rapid ventricular response due to normal conduction through the AV node in HF patients, the fast ventricular rate can cause deleterious consequences in the clinical outcome. Moreover, there are interesting published data which will be analyzed in this manuscript documenting significant acute and long-term improvement in left ventricular function, symptoms, exercise tolerance, clinical outcomes, and quality of life in selected HF patients with paroxysmal and persistent drug-refractory AF who have undergone AVN ablation and permanent pacemaker implantation.