End-stage heart failure (HF) accounts for 1% to 10% of all HF cases. It is frequently associated with coexistent atrial fibrillation due in part to structural changes related to altered hemodynamics, increased wall stress, and neurohormonal activation. The treatment remains challenging because of frequent atrial remodeling, comorbidities, and high recurrence rates. Studies have found no benefit of medical rhythm control compared with rate control. However, recent data suggest that catheter ablation might be associated with a reduction in HF symptomatology and all-cause mortality. Alternative treatment options including AV nodal ablation are available for refractory cases, but should not delay urgent heart transplantation.