October 2023
Catheter ablation again shows benefit in patients with atrial fibrillation and heart failure

The procedure improved clinical outcomes, including all-cause mortality, in patients referred for heart transplantation evaluation.

Numerous randomised trials of catheter ablation for atrial fibrilla­tion, one of the most commonly performed procedures by electrophysiolo­gists, have nearly all shown significant benefits in patients with heart failure and reduced left ventricular ejection fraction (LVEF). Now adding to that evidence is a trial in which researchers randomised 194 patients who had symptomatic atrial fibrillation and LVEF 35% or below, and who were referred for heart transplanta­tion evaluation, to either catheter ablation plus guideline­-directed medical therapy or to guideline­-directed medical therapy alone. The data safety and monitoring board stopped the trial for efficacy one year after randomisation was completed (NCT04649801).

During a median follow up of 18 months, the primary endpoint – a composite of overall mortality, implanta­tion of an LV assist device, and urgent heart transplantation – occurred signifi­cantly less frequently in the ablation group than in the medical therapy­-alone group (8% vs 30%; hazard ratio [HR], 0.24). The benefit of ablation was also evident for all­ cause mortality (6% vs 20%, respectively; HR, 0.29). By one year, LVEF had improved by 7.8 ± 7.6% in the ablation group, compared with 1.4 ± 7.2% in the medical therapy­-alone group; atrial fibrillation burden at one year was reduced by 31% and 8%, respectively.

Comment: In this relatively small rando­mised trial, catheter ablation had quite an impressive benefit in clinical outcomes, including all­-cause mortality. The find­ings should persuade more patients and physicians to be proactive in treating atrial fibrillation in patients with heart failure and reduced ejection fraction.

Mark S. Link, MD, Professor of Medicine and Director, Cardiac Electrophysiology, UT Southwestern Medical Center, Dallas, USA.

Sohns C, et al. for the CASTLE HTx Investigators. Catheter ablation in end-stage heart failure with atrial fibrillation. N Engl J Med 2023 Aug 27; e-pub (https://doi.org/10.1056/NEJMoa2306037).

This summary is taken from the following Journal Watch titles: Cardiology, General Medicine, Ambulatory Medicine, Hospital Medicine.

N Engl J Med