Ablation vs. Medical therapy in patients with AF and heart failure
The AATAC (Ablation vs. Amiodarone for Treatment of Persistent Atrial Fibrillation in Patients with Congestive Heart Failure and an Implanted ICD/CRT-D) trial compared the effect of catheter ablation and rhythm control with amiodarone in patients with AF-associated HF and showed that the sinus rhythm maintenance rate after ablation was significantly higher than after amiodarone therapy (70% vs. 34%), resulting in significant improvements in the QOL and mortality rates.4 Regarding the catheter ablation of AF with heart failure, in addition, Marrouche NF, et al. published in N Engl J Med 2018 that it was associated with a significantly lower rate of a composite end point of death from any cause or hospitalization for worsening HF than was medical therapy.5 In the CASTLE-AF trial, patients were included if they had paroxysmal or persistent AF, a New York Heart Association (NYHA) class II, III, or IV heart failure, and a left ventricular ejection fraction (LVEF) of 35% or less. That is, patients with HF with a reduced EF (HFrEF) were selected in the CASTLE-AF trial. In patients with HF and HFrEF with persistent symptoms despite medical therapy, catheter ablation (CA) is associated with a decreased all-cause mortality, decreased rates of cardiovascular hospitalizations, and lower rates of recurrence as compared to medical therapy.6 In the manuscript published by Sessions AJ, et al.7, the patients were examined according to their ejection fraction (EF): EF ≤35% (n = 1024) and EF >35% (n=8955). They stated that mainly delaying treatment of AF with catheter ablation in patients with concurrent left ventricular dysfunction resulted in an increased all-cause mortality in all patients and significantly increased HF hospitalizations, strokes, and AF recurrence in patients with an EF >35%. Additionally, in patients with an EF ≤35%, it was written that a delay in performing catheter ablation impacted the outcomes, in particular the mortality risk. In the EF ≤35% group, catheter ablation did not impact the stroke rates with early use, however, the stroke event rates were low in this population. Those data in aggregate favor the early use of ablation of AF in patients with HF. Without touching on the early use of ablation of AF in patients with HF, the JCS guidelines determine that catheter ablation therapy in AF patients with HF is an option that can be expected to improve the prognosis and recommends applying the same indication level with or without HF on the basis of some study results at this time.8