What is the best management approach for a patient with dilated cardiomyopathy and symptomatic atrial fibrillation despite full compliance with medical treatment, and is radio-frequency ablation (RFA) immediately needed?

From the Guidelines

For a patient with dilated cardiomyopathy and symptomatic atrial fibrillation despite medication compliance, radiofrequency ablation (RFA) is not immediately needed but should be considered as a second-line treatment option, with a preference for pulsed field ablation due to its better outcomes and less atrial damage, as stated by the patient's doctor 1. The initial approach should focus on optimizing medical therapy, including rate control with beta-blockers (metoprolol 25-200 mg daily, carvedilol 3.125-25 mg twice daily, or bisoprolol 2.5-10 mg daily) and anticoagulation with direct oral anticoagulants (apixaban 5 mg twice daily, rivaroxaban 20 mg daily, or warfarin with INR 2-3) 1. For heart failure management, continue guideline-directed medical therapy including ACE inhibitors/ARBs, beta-blockers, mineralocorticoid receptor antagonists, and possibly SGLT2 inhibitors. Some key points to consider in the management of atrial fibrillation include:

• Optimal treatment according to the AF-CARE pathway, which includes comorbidity and risk factor management, avoiding stroke and thromboembolism, reducing symptoms by rate and rhythm control, and evaluation and dynamic reassessment 1
• The use of anticoagulants, with a preference for direct oral anticoagulants (DOACs) over vitamin K antagonists (VKAs), except in patients with mechanical heart valves and mitral stenosis 1
• The importance of managing modifiable bleeding risk factors to improve safety, and not using bleeding risk scores to decide on starting or withdrawing anticoagulants 1 If symptoms persist despite optimal medical therapy for 3-6 months, then RFA becomes a reasonable option, particularly for patients with reduced quality of life due to atrial fibrillation symptoms. RFA can improve symptoms and cardiac function by maintaining sinus rhythm, reducing tachycardia-mediated cardiomyopathy, and allowing for more effective cardiac resynchronization therapy if applicable. However, success rates may be lower in dilated cardiomyopathy patients due to structural remodeling, and the procedure carries risks including stroke, vascular complications, and cardiac perforation 1. A multidisciplinary heart team discussion involving electrophysiology and heart failure specialists is recommended before proceeding with ablation. The patient's doctor has already considered the different ablation techniques and recommends pulsed field ablation, which should be taken into account when making the decision. It is also important to consider the patient's individual characteristics, such as the severity of symptoms, the presence of comorbidities, and the potential risks and benefits of the procedure. Ultimately, the decision to proceed with RFA should be made on a case-by-case basis, taking into account the latest evidence and guidelines, as well as the patient's unique needs and circumstances 1.

From the Research

Best Management Approach

The best management approach for a patient with dilated cardiomyopathy and symptomatic atrial fibrillation despite full compliance with medical treatment involves considering catheter ablation as a potential treatment option.

• Studies have shown that catheter ablation for atrial fibrillation can improve outcomes in patients with heart failure, including reducing mortality and hospitalization for worsening heart failure 2, 3.
• The patient's left ventricular ejection fraction (LVEF) of 35% and moderate global left ventricular hypokinesia with variable wall motion abnormalities suggest severe left ventricular systolic dysfunction, which may benefit from catheter ablation.
• The fact that the patient's coronary angiography was normal suggests that the heart failure is likely induced by atrial fibrillation, making catheter ablation a potentially effective treatment option.

Need for Radio-Frequency Ablation

Regarding the need for radio-frequency ablation (RFA) specifically,

• While RFA is a common ablation technique, the patient's doctor has recommended pulsed field ablation as the preferred technique due to its better outcomes and less atrial damage.
• Studies have shown that catheter ablation, including RFA, can improve outcomes in patients with atrial fibrillation and heart failure, but the choice of ablation technique may depend on individual patient factors and physician preference 2, 3.
• There is no clear evidence to suggest that RFA is immediately needed, and the decision to proceed with ablation should be based on a thorough evaluation of the patient's condition and discussion with their healthcare provider.

Gold Standard Management

The gold standard management for dilated cardiomyopathy and symptomatic atrial fibrillation involves a comprehensive approach, including:

• Medical therapy to control heart failure symptoms and prevent further cardiac damage
• Rhythm control strategies, such as catheter ablation, to manage atrial fibrillation
• Close monitoring of cardiac function and adjustment of treatment as needed
• Consideration of novel therapies, such as pulsed field ablation, which may offer improved outcomes for certain patients 4, 5.