Clinical Edge

Summaries of Must-Read Clinical Literature, Guidelines, and FDA Actions

Catheter Ablation for AF in Patients with HF

N Engl J Med; 2018 Feb 1; Marrouche, et al

Compared to medical therapy, catheter ablation for atrial fibrillation (AF) in patients with heart failure (HF) was associated with a significantly lower rate of a composite end point of death from any cause or hospitalization from worsening HF, a recent study found. Patients with symptomatic paroxysmal or persistent AF who did not have a response to antiarrhythmic drugs, had unacceptable side effects, or were unwilling to take these drugs to undergo either catheter ablation (179 patients) or medical therapy (184 patients) for AF in addition to guideline-based therapy for HF, were randomly assigned. The primary end point was a composite of death from any cause or hospitalization for worsening HF. Among the findings:

  • The primary composite end point occurred in significantly fewer patients in the ablation group vs the medical-therapy group (51 patients [29%] vs 82 patients [45%]; HR, 0.62) after median follow-up of 37.8 months.
  • Significantly fewer patients in the ablation group died from any cause (24 vs 46; HR, 0.53), were hospitalized for worsening HF (37 [21%] vs 66 [36%]; HR, 0.56), or died from CV causes (20 [11%] vs 41 [22%]; HR, 0.49).

Citation:

Marrouche NF, Brachmann J, Andresen D, et al. Catheter ablation for atrial fibrillation with heart failure. N Engl J Med. 2018;378:417-427. doi:10.1056/NEJMoa1707855.

Commentary:

The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial showed no mortality difference between a rate control vs rhythm control strategy for the treatment of atrial fibrillation (AF). The AFFIRM trial participants, however, were minimally symptomatic and the trial had few patients with heart failure. Studies of patients with heart failure have shown a significant increase in mortality when in atrial fibrillation. Rhythm control trials with antiarrhythmic medications have failed to show a mortality benefit due in part to a high recurrence rate of AF despite medical therapy and a potential for drug toxicity with the antiarrhythmic drugs. Catheter ablation for AF has a higher rate of maintenance of sinus rhythm compared with antiarrhythmic medications. The current study by Marrouche and colleagues reports a lower mortality rate or worsening heart failure in a group of heart failure patients undergoing AF ablation. This study suggests that catheter ablation of AF may become a treatment of choice for advanced heart failure patients. — Matthew Sorrentino, MD, FACC, FASH

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