Practice Update - ESC Congress 2017

Catheter Ablation Improves Outcomes in Patients With Heart Failure and Atrial Fibrillation – CASTLE-AF Trial

13.4% with catheter ablation vs 25% with conventional treatment (hazard ratio 0.53; 95% confidence interval 0.32–0.86; P = .011). Rates of heart failure hospitalization were 20.7% with catheter ablation vs 35.9% with conventional treatment (0.56; 95% confi- dence interval 0.37–0.83; P = .004). Dr. Marrouche noted that compared to those receiving conven- tional treatment, patients receiving catheter ablation were 38% less likely to experience the primary endpoint, 47% less likely to die, and 44% less likely to be hospitalized with worsening heart failure. “A significant number of patients undergoing ablation were still in normal rhythm at the end of the study,” he said. Dr. Marrouche added that the study also carried limitations, namely that all patients had a previous implantable cardioverter defibrilla- tor implanted, which may have affected mortality in both groups. He said, “Nevertheless, this clinical trial sheds light on the impor- tance of restoring and maintaining regular heart rhythm with ablation.” “The findings of CASTLE-AF will help not only save the lives of many patients suffering from heart failure and atrial fibrillation but will also exert a major impact on the cost of treating these patients by keeping them out of hospital,” he said. According to stopafib.org, a patient-driven information site about atrial fibrillation, catheter ablation has evolved over time. “The most frequent catheter ablation done today is the radiofrequency catheter ablation. It is typically some variation of pulmonary vein isolation (PVI). The goal of the procedure is to eliminate the irreg- ular heartbeat that research has shown typically originates from the four pulmonary veins and is most successful with paroxysmal atrial fibrillation.”

Catheter ablation may improve outcomes for patients with left ventricular dysfunction and atrial fibrillation. Patients who received catheter ablation of atrial fibrillation had lower mortality and less hospitalization for worsening heart failure than those receiving conventional drug treatment.

Dr. Nassir F. Marrouche

T his outcome of Catheter Ablation vs Standard conven- tional Treatment in patients with LV dysfunction and AF (CASTLE-AF) was reported at the 2017 European Society of Cardiology (ESC) Congress, from August 26–30. “Themedical community continues to debate the ideal treatment for atrial fibrillation in patients with left ventricular dysfunction because clinical studies that support one definitive treatment are lacking. Common therapies for atrial fibrillation include medication that reg- ulates or slows the heart rate,” said Nassir F. Marrouche, MD, of the Comprehensive Arrhythmia Research and Management (CARMA) Centre, University of Utah Health, Salt Lake City Dr. Marrouche and Johannes Brachmann, MD, of the Klinikum Coburg, Germany, jointly conducted a clinical trial to examine the effect of catheter ablation on all-causemortality and hospitalization rates in patients with atrial fibrillation and left ventricular dysfunc- tion, vs state-of-the art conventional treatment recommended by the American Heart Association and European Society of Cardiology. CASTLE-AF is the first randomized clinical trial comparing catheter ablation to current first-line antiarrhythmic drug therapy for patients with coexisting heart failure (HF) and atrial fibrillation evaluating the primary outcome of mortality and hospitalization for worsening heart failure. After screeningmore than 3000 patients, CASTLE-AF included 397 patients with symptomatic paroxysmal or persistent atrial fibrillation and heart failure with ejection fraction <35%. All patients were supplied with an implantable cardioverter defi- brillator with home monitoring capability to enable continuous surveillance of atrial fibrillation. Patients were recruited frommore than 30 clinical centers fromNorth America, Europe, and Australia. Patients were randomized to radiofrequency catheter ablation or conventional drug treatment (rhythm control or rate control) for atrial fibrillation. The primary endpoint was the composite of all-cause mortality and unplanned hospitalization for worsening heart failure. During a median follow-up of 37.8 months, the rate of the primary endpoint was significantly lower in the ablation group (28.5%) vs the control group (44.6%; hazard ratio 0.62; 95% confidence interval 0.43–0.87; P = .007). The secondary endpoints of all-cause mortality and heart failure hospitalization were also significantly lower with catheter ablation than with conventional treatment. Rates of all-causemortality were

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