We consider epidemic extinction in finite networks with a broad variation in local connectivity. Generalizing the theory of large fluctuations to random networks with a given degree distribution, we are able to predict the most probable, or optimal, paths to extinction in various configurations, including truncated power laws. We find that paths for heterogeneous networks follow a limiting form in which infection first decreases in low-degree nodes, which triggers a rapid extinction in high-degree nodes, and finishes with a residual low-degree extinction. The usefulness of our approach is further demonstrated through optimal control strategies that leverage the dependence of finite-size fluctuations on network topology. Interestingly, we find that the optimal control is a mix of treating both high- and low-degree nodes based on theoretical predictions, in contrast to methods that ignore dynamical fluctuations.