Catheter Ablation of Atrial Fibrillation in Patients with Heart Failure: Focus on the Latest Clinical Evidence
Abstract
:1. Introduction
2. The Prognostic Meaning of Rhythm vs. Rate Control Strategies
3. The Effect of CA on LVEF
4. HF and CA Technique
5. CA across the LVEF Spectrum: HFpEF
6. CA across the LVEF Spectrum: End-Stage HF
7. Healthcare Cost Implications
8. Conclusions
Author Contributions
Funding
Data Availability Statement
Conflicts of Interest
References
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CASTLE-AF | RAFT-AF | CASTLE-HTX | AMICA TRIAL | CAMERA- MRI | |
---|---|---|---|---|---|
Year | 2018 | 2022 | 2023 | 2019 | 2017 |
Design | Multicenter open label RCT | Multicenter open-label RCT | Single-center open-label RCT | Multicenter open-label RCT | Multicenter RCT |
Mean age (years) | 64 ± 5 | 67 ± 8 | 64 ± 11 | 65 ± 8 | 61 ± 10 |
AF type | Parox: 32.5% Pers: 38.3% LS-pers: 29.2% | Parox: 7.3% Pers: 69.3% LS-pers: 23.4% | Parox: 30% Pers: 56% LS-pers: 14% | Pers: 76.4% LS-pers: 23.6% | Pers: 100% |
Baseline LVEF | 25–38% | 41 ± 15% | 27 ± 6% | 26 ± 9% | 33 ± 9% |
NYHA | I: 11% II: 60% III: 28% IV: 1% | II: 67% III: 33% | II: 31% III: 55% IV: 14% | II: 39% III: 61% | Mean NYHA class: 2.5 ± 0.6 |
Adjunctive ablation targets other than PVI | ND | 91.2% | ND | 33% | 100% |
Control arm therapy | Medical therapy | Rate control | Guideline directed | Best medical therapy | Rate control |
Primary outcome | All-cause mortality and HF hospitalization | All-cause mortality and HF events | Death from any cause, LVAD implantation or urgent heart TX | Absolute increase in LVEF | Change in LVEF at 6 months |
Mean change in LVEF (ablation vs. control) | 8.0% vs. 0.2% | 10.1 ± 1.2 vs. 3.8 ± 1.2 | 7.8 ± 7.6 vs. 1.4 ± 7.2 | 8.8% vs. 7.3% | 18.3% vs. 4.4% |
Rhythm control outcome (ablation vs. control) | 63.1 vs. 21.7% in SR (5 years) | 85.6 vs. 12.9% in SR at 2 years | 31.4 ± 33.3 vs. 8.6 ± 26.3 AF burden reduction at 1 year | 73.5% vs. 50% in SR | 25% vs. 100% in AF |
Main findings | Reduction in all-cause death or HF hospitalization | Similar primary outcomes and increase in LVEF | Reduction in primary composite endpoint | No LVEF improvement | LVEF improvement |
Follow-up (months) | 38 | 37 | 18 | 12 | 6 |
CABANA Subanalysis [50] | EAST-AFNET 4 [51] | Xie et al. [52] | Tsuda et al. [53] | Ratkka et al. [54] | Olshausen et al. [55] | |
---|---|---|---|---|---|---|
Year | 2021 | 2021 | 2023 | 2023 | 2021 | 2022 |
Design | RCT post hoc analysis | RCT post hoc analysis | Retrospective, observational | Retrospective, observational | Retrospective, observational | Retrospective, observational |
Mean age (years) | 68 ± 8 | >75 | 63–76 | 68.4 | 61 ± 10 | Ablation arm mean age: 67 Non-ablation arm mean age: 77 |
AF type | Parox: 31.6% Pers: 55.3% LS-pers: 13.1% | Ablation arm: Parox: 33.2% Pers: 32.2% Non-ablation: Parox: - Pers: 40% | Ablation arm: Pers: 63.5% Non-ablation: Pers: 61.8% | Ablation arm: Pers: 77.4% Non-ablation: Pers: 77.4% | Ablation arm: Parox: 60% Pers: 40% Non-ablation: Parox: 51% Pers: 49% | Ablation arm: Parox: 17.1% Pers: 32.7% Non-ablation: Parox: 17.5% Pers: 35.9% |
Ablation/no ablation | 295/315 | 224/218 | 293/293 | 106/106 | 43/43 | 434/868 |
Control arm therapy | Medical therapy (rate or rhythm control) | Rate control | Medical therapy (rate or rhythm control) | Medical therapy (rate or rhythm control) | Medical therapy (rate or rhythm control) | Medical therapy (rate or rhythm control) |
Primary outcome | All-cause mortality, disabling stroke, serious bleeding and cardiac arrest | All-cause mortality and HF events | Death from any cause or HF rehospitalization | Reduction in death or heart failure | Time to death or HF hospitalization | All-cause mortality and first HF hospitalization |
Main findings | Reduction in primary composite, all-cause mortality and improvement QoL | Sinus rhythm at 12 months explains 81% of effect of early rhythm control on preventing cardiovascular outcomes | Reduction in primary composite endpoint | Reduction in primary composite endpoint | Reduction in HF hospitalization and HF symptoms and improvement in diastolic function | Reduction in primary composite endpoint |
Follow-up (months) | 60 | 37.4 | 39 | 24.6 | 35 ± 22 | 6.1 |
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Demarchi, A.; Casula, M.; Annoni, G.; Foti, M.; Rordorf, R. Catheter Ablation of Atrial Fibrillation in Patients with Heart Failure: Focus on the Latest Clinical Evidence. J. Clin. Med. 2024, 13, 5138. https://doi.org/10.3390/jcm13175138
Demarchi A, Casula M, Annoni G, Foti M, Rordorf R. Catheter Ablation of Atrial Fibrillation in Patients with Heart Failure: Focus on the Latest Clinical Evidence. Journal of Clinical Medicine. 2024; 13(17):5138. https://doi.org/10.3390/jcm13175138
Chicago/Turabian StyleDemarchi, Andrea, Matteo Casula, Ginevra Annoni, Marco Foti, and Roberto Rordorf. 2024. "Catheter Ablation of Atrial Fibrillation in Patients with Heart Failure: Focus on the Latest Clinical Evidence" Journal of Clinical Medicine 13, no. 17: 5138. https://doi.org/10.3390/jcm13175138