RAFT - Pace &Ablate

Inclusion Criteria: 1. Patients with permanent AF/persistent AF (in AF) 2. Patients with NYHA Class II -IVa HF symptoms 3. Guideline driven medical therapy (GDMT) for HF for at least 3 months: * for those \< 75 years of age with an NT-proBNP of ≥ 600 ng/L * for those ≥ 75 years of age with an NT-proBNP ≥ 900 ng/L, or ≥ 600 ng/L if the patient has had a HF hospitalization within 1 year Exclusion Criteria: 1. In hospital patients needing intensive care or intravenous inotropic agent in the last 4 days 2. Patients with a life expectancy of ≤ 1 year from non-cardiac cause or anticipating a transplant within 1 year 3. Acute coronary syndrome \<4 weeks or coronary revascularization \<3months 4. Unable or unwilling to provide informed consent 5. Uncorrected primary valvular disease or prosthetic tricuspid valve 6. Restrictive, hypertrophic, or irreversible form of cardiomyopathy 7. Severe pulmonary diseases requiring oxygenation 8. Patients with a known history of WHO Class I pulmonary hypertension (PH) which includes PH associated with CVD, collagen vascular disease, congenital shunts, cirrhosis and portal hypertension, HIV, hemoglobinopathies, schistosomiasis or drug-associated PH as well as those with high suspicion of irreversible pulmonary hypertension 9. Patients enrolled in competitive clinical trials that will affect the objectives of this study 10. Existing CRT/BiVP 11. Patients who are pregnant 12. Guideline indication for CRT 13. More than 20% pacing with an existing pacemaker 14. Severe mobility limitations (ex. wheelchair bound and severe neurological conditions that limit mobility)