Does atrial fibrillation (AF) ablation have a Class 1 indication in patients with heart failure (HF)?

From the Guidelines

Atrial fibrillation ablation has a Class I indication in patients with heart failure with reduced ejection fraction (HFrEF) who have symptomatic atrial fibrillation that is refractory to or intolerant of at least one Class I or III antiarrhythmic medication, as it can improve symptoms, quality of life, exercise capacity, and left ventricular function while reducing heart failure hospitalizations. This recommendation is based on the most recent and highest quality study, which showed that ablation in these patients can lead to a significant reduction in hospitalizations and mortality 1. The procedure typically involves pulmonary vein isolation, with additional ablation targets as needed based on the individual's arrhythmia characteristics.

Key Considerations

• The benefit of ablation appears most pronounced in patients with tachycardia-induced cardiomyopathy, where controlling the rhythm can lead to substantial recovery of ventricular function.
• Patients should continue guideline-directed medical therapy for heart failure alongside rhythm control strategies.
• Success rates are generally lower in heart failure patients compared to those with normal cardiac function, and multiple procedures may be required.
• The 2022 AHA/ACC/HFSA guideline for the management of heart failure recommends catheter ablation as a treatment option for patients with HFrEF and symptomatic atrial fibrillation, based on evidence from large RCTs such as the AATAC and CASTLE AF trials 1.

Evidence Summary

• The AATAC trial showed that ablation improved the likelihood of maintaining normal sinus rhythm at 24 months compared with amiodarone, and had a 45% decrease in hospitalization and decrease in mortality (8% vs. 18%) 1.
• The CASTLE AF trial randomized 363 patients with paroxysmal or persistent AF, LVEF <35%, NYHA class II to IV HF, and ICD to ablation versus standard medical care, and found that the composite endpoint of death or rehospitalization was lower in ablation (28.5%) compared with standard care (44.6%) 1.
• A meta-analysis of 11 RCTs comparing rhythm versus rate control found that patients undergoing catheter ablation had improved survival (49% relative risk reduction) and reduced hospitalizations (56% relative risk reduction) 1.

From the Research

Atrial Fibrillation Ablation in Heart Failure

• Atrial fibrillation (AF) ablation has been shown to be effective in improving outcomes for patients with heart failure (HF) 2, 3.
• Recent studies have demonstrated that AF ablation can reduce mortality and hospitalization for heart failure, and improve quality of life, when compared to medical therapy alone 4, 2.
• The treatment of AF in HF is focused on relieving patients from AF-related symptoms and risk reduction for thromboembolism and the occurrence or worsening of HF 5.
• Catheter ablation of AF in HF seems to be a safe and effective solution to obtain rhythm control and improve outcomes 2.

Indications for Atrial Fibrillation Ablation

• AF ablation has been performed in patients without overt HF successfully for many years, and recent attempts have been made to extend this treatment to patients with HF 5.
• The role of patient selection is crucial in optimizing outcomes for patients with AF and HF, and a better selection of patients could help avoid futile procedures and identify patients requiring closer follow-up or additional treatments 2, 3.
• While there is no unanimous consensus on the therapeutic strategy for AF in HF, several randomized controlled trials have shown that AF ablation is superior to medical therapy alone in patients with HF with reduced ejection fraction 4.

Clinical Evidence

• Studies have demonstrated that His bundle pacing in conjunction with atrioventricular node ablation can provide long-term clinical benefits for AF patients with HF who suffer from symptoms despite optimal medical therapy or have failed AF ablation 6.
• Recent reviews have summarized the updated evidence guiding clinical decision-making in the treatment of AF in HF, with a focus on the latest trials and meta-analyses examining the role of catheter ablation in rhythm control 4, 2, 3.