Catheter Ablation in Patients with Heart Failure and Atrial Fibrillation

By Mark H. Drazner, M.D., M.Sc.

Professor of Internal Medicine
Clinical Chief of Cardiology

At #AHA24, I had the honor of participating as a panelist in the Main Event session titled “Fellowship of the Ring: Atrial Fibrillation and Heart Failure, a Collaborative Journey Through the New Middle Earth.” Aimed at bridging the heart failure (HF) and electrophysiology communities, this session reflected on the evolving management of atrial fibrillation (AFib) in patients with HF based on recent pivotal clinical trials that have reshaped clinical practice.

For those who haven’t reviewed the 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation, chaired by my UTSW colleague Jose Joglar, M.D., I highly recommend it. This comprehensive guideline underscores the critical role of catheter ablation for AFib, granting it a Class 1A recommendation for patients with HF with reduced ejection fraction when procedural success is reasonably anticipated.

Our session delved into the role of catheter ablation for patients with advanced HF, a central focus of my clinical practice. Notably, Christian Sohns, M.D., Ph.D., lead author of the 2023 CASTLE-HTx trial published in the New England Journal of Medicine, presented compelling data highlighting improved outcomes for patients listed for heart transplantation. While this study supports catheter ablation in this population, it sparked a debate regarding the applicability of its findings to patients with truly advanced HF, where mortality rates often far exceed the 15% reported for the nonintervention group in CASTLE-HTx.

As I shared during the session, CASTLE-HTx builds on prior evidence from the past five to eight years, influencing my practice to increase referrals for catheter ablation of atrial fibrillation in appropriate patients with heart failure. However, I await further studies to confirm its safety and efficacy in those with truly advanced HF. These discussions emphasized parallels with other therapies, such as cardiac resynchronization in inotrope-dependent patients, raising important questions about benefit in more advanced states.

Overall, this Main Event at #AHA24 brought the HF and electrophysiology communities together in fellowship for the shared goal of improving outcomes for the many patients with HF who also have AFib.