Catheter ablation saves lives in end-stage HF with AF

Catheter ablation outperformed medical therapy for treating atrial fibrillation (AF) in patients with end-stage heart failure (HF) in the CASTLE-HTx trial. This effect was mostly driven by a reduction in all-cause mortality in the ablation arm and could be explained by an improved left ventricular (LV) function and a decreased AF burden in patients who underwent ablation.

“Although we know that catheter ablation reduces mortality and worsening of HF in patients with HF and symptomatic AF, it is not yet established whether this effect translates to patients with end-stage HF eligible for heart transplant or LV assist device,” argued Prof. Christian Sohns (Heart and Diabetes Center NRW, Germany) [1,2]. To investigate this matter, the CASTLE-HTx trial (NCT04649801) randomised 194 participants with end-stage HF and symptomatic AF who were potential candidates for heart transplantation 1:1 to catheter ablation and guideline-directed medical therapy or medical therapy alone [3]. The primary outcome was a composite of all-cause mortality, LV assist device implantation, or urgent heart transplantation. The trial was terminated for efficacy earlier than planned, after 18 months of follow-up.

Ablation was superior to medical therapy in terms of the primary endpoint (HR 0.24; 95% CI 0.11–0.52; P<0.001). This effect was mainly driven by a reduction in death from any cause in the ablation arm (HR 0.09; 95% CI 0.01–0.70; P<0.005). LV assist device implantations (n=10 vs n=1) and urgent heart transplantations (n=6 vs n=1) both occurred more frequently in the medical therapy arm. Prof. Sohns showed that these effects can be explained by an improved LV function and a reduced AF burden in the ablation arm compared with the medical therapy arm (see Figure).

Figure: Impact on left ventricular function and AF burden [2]



In conclusion, ablation for AF led to fewer deaths, LV assist device implantations, and urgent heart transplantation in patients with end-stage HF, as compared with medical therapy alone.

1. 
   
   1. Marrouche NF, et al. N Engl J Med 2018;378(5):417–427.
   2. Sohns C, et al. CASTLE-HTx: Catheter ablation versus medical therapy to treat atrial fibrillation in end-stage heart failure. Hot Line Session 6, ESC Congress 2023, 25–28 August, Amsterdam, the Netherlands.
   3. Sohns C, et al. N Engl J Med 2023; Aug 27. DOI: 10.1056/NEJMoa2306037.

 

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Posted on 30 October 202330 October 2023