From the Guidelines
Catheter ablation should be considered as a treatment option for patients with atrial fibrillation (AF) and heart failure, particularly when symptoms persist despite optimal medical therapy, as it can significantly improve outcomes, including reduced heart failure hospitalizations and improved survival 1.
Benefits of Catheter Ablation
The procedure involves isolating the pulmonary veins using radiofrequency or cryoablation techniques to prevent abnormal electrical signals from triggering AF. Benefits of catheter ablation include:
- Improved ejection fraction (often by 10-15%)
- Reduced heart failure hospitalizations (by approximately 45%)
- Better symptom control
- Potentially improved survival
Patient Selection and Management
Patients with heart failure and AF should continue their heart failure medications (beta-blockers, ACE inhibitors/ARBs, diuretics, and aldosterone antagonists) throughout the periablation period. Anticoagulation management requires careful coordination, with anticoagulation typically bridged with low molecular weight heparin and resumed post-procedure.
Success Rates and Complications
Success rates are approximately 60-80% after a single procedure, with some patients requiring repeat ablations. Complications are rare (1-5%) but include vascular access issues, cardiac tamponade, stroke, and pulmonary vein stenosis.
Recent Evidence and Guidelines
Recent studies, such as the AATAC-AF and CASTLE-AF trials, have shown that AF ablation may be associated with improvement in prognostic surrogates for HF outcomes, including hospitalization for worsening HF and mortality 1. The European Heart Journal recommends considering catheter ablation in patients with concomitant AF and heart failure, particularly when symptoms persist despite optimal medical therapy 1.
Future Directions
Advanced AF-trigger and substrate modification concepts, such as three-dimensional electroanatomical mapping and focal impulse and rotor modulation techniques, may improve ablation outcome. Pre-ablation MRI-derived LGE plays an increasing role in atrial tissue characterization and localization of atrial fibrosis, and may enable non-fluoroscopic MRI-guided catheter ablation of the patient’s individual AF substrate 1.
From the Research
Plan for Catheter Ablation in Atrial Fibrillation (AF) and Heart Failure
The plan for catheter ablation in a patient with atrial fibrillation (AF) and heart failure involves several key considerations:
- Catheter ablation is recommended as a second-line therapy for patients with symptomatic paroxysmal or persistent AF who have failed or are intolerant to pharmacological therapy 2.
- In patients with heart failure and reduced left-ventricular fraction, catheter ablation has been proven to reduce all-cause mortality 2, 3, 4.
- The primary ablation tool in widespread use is single-tip catheter radiofrequency (RF) based ablation, while balloon-based pulmonary vein isolation (PVI) has also gained prominence due to its user-friendly nature and established safety and efficacy profile 2.
- Cryoballoon (CB) based PVI is characterized by high efficiency, convincing success rates, and a beneficial safety profile, and has been shown to be superior to pharmacological treatment in terms of efficacy and reducing progression from paroxysmal to persistent AF 2.
- Non-thermal energy sources, such as pulsed-field ablation (PFA), have garnered attention due to their cardioselectivity 2.
Patient Selection and Outcomes
- An appropriate patient selection strategy for patients with heart failure with reduced ejection fraction (HFrEF) could be the next step in determining which patients might benefit most from catheter ablation 3.
- Catheter ablation of AF in heart failure seems to improve the quality of life, life expectancy, and prognosis, and reduces mortality and hospitalization for heart failure 4, 5.
- Early rhythm-control strategy in AF may reduce cardiovascular death, stroke, hospitalization for HF, or acute coronary syndrome 4.
- Freedom from AF after ≥1 procedure was 71%, and major complications occurred in 8% of patients 5.
Comparison with Medical Therapy
- Catheter ablation is superior to medical therapy for AF in patients with heart failure, resulting in greater improvement in left ventricular ejection fraction (LVEF), quality of life, and functional status, with a survival benefit 5.
- Catheter ablation, compared to medical therapy, is associated with greater improvement in LVEF, greater increase in 6-minute walk test (6MWT) distance, improved quality of life, and significantly reduced mid-term mortality 5.