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