Atrial Fibrillation and Heart Failure

Abstract

Atrial fibrillation (AF) is the most common sustained arrhythmia worldwide and has a strong association with heart failure (HF). It often remains unclear if HF is the cause or consequence of AF due to the complexity of the processes that are involved in both the perpetuation of AF and the development of HF. To date, two therapeutic strategies are accepted as the standard of care in AF patients with heart failure. Rhythm control aims to permanently restore sinus rhythm, whereas a rate-control strategy aims to slow ventricular rate without the termination of AF. In the last 5 years a tremendous number of important studies have been published investigating the optimal therapeutic strategy in HF patients. This review highlights the important studies with respect to the involvement of AF in promoting left-ventricular dysfunction and discusses the optimal strategy in HF patients suffering from AF.

Keywords: atrial fibrillation; catheter ablation; heart failure; remodeling.

Figure 1

(A) High-density 3D map of the left atrium (LA) after pulmonary vein isolation (PVI). View from posterior to anterior. The red dots depict the ablation line encircling the right and left pulmonary veins. The red color indicates that the veins are isolated, and the violet color corresponds to healthy myocardium. (B) Termination of atypical flutter through application of a septal line connecting the mitral annulus with the right superior pulmonary vein (RSPV) depicted in grey. The real-time ECG on the left shows the termination into stable sinus rhythm. In contrast to (A), the LA shows extensive fibrosis (green = left atrial appendage).

Figure 2

Vicious circle between atrial fibrillation and heart failure. Irregular activation impairs left-ventricular function by intracellular production of reactive oxygen species. This leads to impaired LV-Ca²⁺-handling and electric remodeling. In heart failure, filling pressures are increased and the neurohumoral cascade is activated. Both contribute to electric and structural remodeling of the atria.