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The optimal medical treatment can fail in the intention to improve symptoms and quality of life of heart failure (HF) patients with severe left ventricular dysfunction and atrial fibrillation (AF) with uncontrolled ventricular rate. In these refractory cases to medical management, the necessity to utilize cardiac resynchronization therapy (CRT), or the need to use catheter ablation, or both, emerges in order to achieve hemodynamic improvement. Several clinical studies with CRT demonstrated structural and functional ventricular improvement. Moreover, there are additional beneficial effects in left ventricular remodeling. It was demonstrated that there is a significant improvement in left ventricular ejection fraction, and a significant decrease in end systolic and end diastolic volumes. However, CRT may be interrupted in over 30% of patients after successful implantation of a device and the most common reason for CRT interruption is the development of AF in 18% of the cases. Those patients whom do not respond to drug therapy will require atrioventricular nodal (AVN) catheter ablation in order to restore 100% CRT functionality and improvements in clinical outcomes. There are interesting published data documenting significant acute and longterm improvement in left ventricular function, cardiac performance, 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.

AV Nodal Ablation in Heart Failure Patients with Atrial Fibrillation