Key points

Introduction

Atrial fibrillation (AF) and heart failure (HF) each affect tens of millions worldwide with prevalence predicted to increase in the coming years. ^, Due to a combination of shared risk factors and interdependent pathophysiology, AF and HF frequently coexist, with AF present in half of patients with HF, and HF present in one-third of patients with AF. Critically, the presence of AF is associated with a poor HF prognosis regardless of left ventricular (LV) systolic function. Therefore, management of AF in patients with HF requires special consideration, with recent American College of Cardiology (ACC)/American Heart Association (AHA) /Heart Rhythm Society (HRS) and European Society of Cardiology (ESC) guidelines supporting the use of catheter ablation (CA) to achieve early rhythm control. ^, This review will detail evidence for the use of CA in treating AF in HF with particular attention to those with heart failure and reduced ejection fraction (HFrEF).

Risk factors and pathophysiology

AF and HF share numerous risk factors, many of which are modifiable. ^, Maintaining adequate physical activity, reducing obesity, alcohol and tobacco cessation, and adequate management of hypertension and diabetes are all recommended for primary prevention of AF as well as mitigation of AF burden and symptoms. These risk factors also play a considerable role in the development of HF as well as atherosclerotic cardiovascular disease which is itself a preventable risk factor for both AF and HF. ^,

Mechanistically, the elevated LV and left atrial (LA) filling pressures associated with HF are understood to induce electrophysiologic and neurohormonally mediated changes to LA structure which promote and support AF. ^, Once established, AF itself leads to further LA fibrosis leading to a cycle in which AF begets AF. Furthermore, AF can induce LV fibrosis, contributing to LV dysfunction, cardiomyopathy, and HF. AF is the most common arrhythmia leading to arrhythmia-induced cardiomyopathy that may be partially or fully reversible if identified and treated early.

Early rhythm control

Given the adverse effects of AF on LV function, one would expect a clinical benefit from the maintenance of SR. The AFFIRM trial compared rate versus pharmacologic rhythm control in a population at high risk for stroke or death, of which 23% had HF; no survival benefit of rhythm control compared to rate control was seen. Further subgroup analysis showed that while sinus rhythm (SR) was associated with improved survival, use of antiarrhythmic drugs (AADs)—38% of which was amiodarone—was not, suggesting that the benefit of AADs are balanced by their adverse effects. The AF-CHF trial would later show this to hold true in the HFrEF population specifically, raising the question of whether non-pharmacologic rhythm control strategies would confer a survival benefit. More recently, the EAST-AFNET 4 trial comparing rhythm control initiated within 1 year of AF diagnosis to usual care in patients with cardiovascular risk factors demonstrated a significant reduction of the composite endpoint of death from cardiovascular cause, stroke, and hospitalization for HF or acute coronary syndrome (HR 0.79 96% CI 0.66–0.94) as well as the individual components of cardiovascular death (HR 0.72 95% CI 0.52–0.98) and stroke (HR 0.65 95% CI 0.44–0.97). The presence of heart failure did not alter the reduction in the composite endpoint ( P -value for interaction 0.63).

Based on these findings and others, the most recent ACC/AHA/American college of clinical pharmacy (ACCP)/HRS guidelines for management of AF recommend “early and aggressive” rhythm control in patients with HF. As a strategy for maintaining SR in patients with AF, CA has been shown to be more effective than AADs without an increase in major adverse events. The use of CA for rhythm control in HF will be discussed in detail later.

Catheter ablation in heart failure with reduced ejection fraction

Relevant studies of CA in HFrEF are detailed in Table 1 . Several early randomized clinical trials (RCTs) comparing the use of CA for rhythm control to medical therapy in patients with AF and HF focused mainly on markers of LV function, functional status, and quality of life metrics. In a small population of patients with a baseline LV ejection fraction (LVEF) ≤35%, MacDonald et al. were the first to show that CA was superior to rate control in improving LVEF (8.2% vs 1.4% improvement in CA and rate control, respectively) as well as some, but not all, quality of life metrics. The ARC-HF and CAMTAF trials would later support these findings, each showing that CA was superior to medical rate control in improving LVEF, quality of life, maximum oxygen consumption, and serum brain natriuretic peptide (BNP) levels. ^, The CAMTAF trial is of particular note for the inclusion of patients with reduced as well as mid-range LVEF.

Table 1

Catheter ablation trials and meta-analyses in patients with heart failure and reduced ejection fraction

Study	Study Design	Intervention (Patients per Arm)	Enrollment Criteria	Primary Endpoint	Secondary Endpoints	Major Findings	Notes
MacDonald et al, 2011	Randomized clinical trial	Catheter ablation (CA) (22) vs rate control (19)	1. Permanent atrial fibrillation (AF) 2. Left ventricular ejection fraction (LVEF) ≤ 35% 3. New York Heart Association (NYHA) II-IV	LVEF by cardiac magnetic resonance imaging (cMRI) at 6 mo	1. Radionucleide LVEF 2. LVESV, LVEDV, LAEDA 3. Quality of life (QOL)	CA superior in improving radionucleide LVEF∗ and QOL∗∗	∗Superior radionucleide LVEF, no difference observed by cMRI ∗∗Superior in SF-36. Unchanged KCCQ, MLHFQ, 6MWD
ARC-HF	RCT	CA (26) vs rate control (26)	1. Persistent AF 2. LVEF≤35% 3. NYHA II-IV	Peak V o 2 at 12 mo	1. QOL 2. Brain natriuretic peptide (BNP) 3. 6MWT 4. LVEF	CA superior in improving peak V o 2 , QOL∗, and BNP. Trend toward superior improvement in LVEF∗∗ and 6MWD.∗∗∗	∗MLHFQ ∗∗ P = .055 ∗∗∗ P = .095
CAMTAF	RCT	CA (26) vs rate control (24)	1. Persistent AF 2. LVEF≤50% 3. NYHA II-IV	LVEF at 6 mo	1. LVESV 2. V o 2 max 3. BNP 4. QOL	CA superior in improving LVEF, QOL∗, V o 2 max, and BNP.	∗MLHFQ, NYHA class
AATAC	RCT	CA (102) vs amiodarone (101)	1. Persistent AF 2. LVEF ≤ 40% 3. Dual chamber ICD or CRTD 4. NYHA II-III	Freedom from atrial arrhythmia over 3 y	1. All-cause mortality 2. Unplanned hospitalization	CA superior in maintaining SR, reducing mortality and hospitalization.
CAMERA-MRI	RCT	CA (33) vs rate control (33)	1. Persistent AF 2. LVEF ≤ 45% 3. New York Hear Association (NYHA) II-IV 4. Idiopathic left ventricular dysfunction without significant coronary artery disease	LVEF by cMRI at 6 mo	1. Change in CMR chamber dimensions 2. NYHA class 3. BNP 4. 6MWT∗ 5. QOL∗ 6. AF recurrence 7. AF burden 8. Procedural complications	CA superior in improving LVEF, BNP, and NYHA class.	∗No difference observed in 6MWD or SF36
CASTLE-HF	RCT	CA (179) vs medical therapy (183)∗	1. Symptomatic paroxysmal or permanent AF, unresponsive to or unable to tolerate antiarrhythmic drugs 2. LVEF≤35%, with an ICD 3. NYHA II-IV	Composite all-cause mortality or heart failure (HF) hospitalization	1. Mortality 2. HF hospitalization 3. CV Mortality 4. CVA 5. CV hospitalization 6. Any hospitalization	CA superior in reducing primary composite outcome, all-cause mortality, HF hospitalization, CV death, and CV hospitalization.	∗Rhythm control was recommended
AMICA	RCT	CA (103) vs medical therapy (98)∗	1. Persistent AF 2. LVEF ≤35% 3. Indication for ICD or CRT-D 4. Optimal medical HF treatment for 1-y	LVEF at 12 mo	1. 6MWT 2. QOL 3. BNP	Similar improvement in LVEF observed in both arms.	∗Including rate and rhythm control
Turagam et al, 2019	Meta-analysis	CA (388) vs medical therapy (387)	1. Persistent or recurrent AF 2. All trials included LVEF≤45%	All-cause mortality	1. Hospitalization 2. AF recurrence 3. LVEF 4. QOL 5. 6MWT	CA superior in reducing mortality, re-hospitalization, and AF recurrence and improving LVEF, and QOL.
Chen et al, 2020	Meta-analysis	CA (507) vs medical therapy (498)	1. Paroxysmal or permanent AF 2. Predominantly reduced LVEF∗	1. All-cause mortality 2. Re-hospitalizatoin 3. Stroke	1. LVEF 2. AF Recurrence 3. QOL	CA superior in reducing mortality, re-hospitalization, and AF recurrence and improving LVEF and QOL.	∗Inclusion of CABANA trial which entrolled patients with preserved LVEF
Pan et al, 2021	Meta-analysis	CA (388) vs medical therapy (387)	1. Persistent or recurrent AF 2. All trials included LVEF≤45%	All-cause mortality	1. Hospitalization 2. AF recurrence 3. LVEF 4. QOL 5. 6MWT	CA superior in reducing mortality, re-hospitalization, and AF recurrence and improving LVEF and QOL.
CABANA	RCT	CA (378) vs medical therapy (400)∗	1. Peristent or paroxysmal AF 2. NYHA II-IV∗∗	Composite mortality, disabling stroke, serious bleeding, or cardiac arrest	1. All-Cause mortality 2. HF hospitalization	CA superior in reducing composite end point, all-cause mortality, AF recurrence, HF hospitalization, and improving QOL.∗∗∗	∗Including rate or rhythm control ∗∗6.8% had LVEF<40, 8.7% had LVEF 40%–50%, 57.7% had EF>50%. 27% did not have a baseline LVEF ∗∗∗MAFSI, AFEQT
RAFT-AF	RCT	CA (214) vs rate control (197)	1. High burden paroxysmal or persistent AF 2. NYHA II-III 3. On guideline-directed medical therapy 4. Elevated BNP	Composite all-cause mortality, all HF events	1. LVEF 2. 6MWT 3. QOL 4. BNP	Non-significant trend toward improvement in primary outcome with CA.∗∗ Significant improvement in secondary outcomes.∗∗∗	58% with LVEF≤45% ∗∗ P = .066 ∗∗∗MLHFQ, AFEQT
Castle-HTx	RCT	CA (97) vs medical therapy (97)∗	1. Symptomatic AF 2. LVEF≤35% 3. NYHA II-IV and impaired 6MWT 4. Referred for left ventricular assist device (LVAD) or transplant	Composite mortality, implantation of LVAD, or heart transplant	1. Mortality 2. LVAD implantation 3. Heart transplant 4. CV Mortality 5. LVEF 6. AF burden	CA superior in reducing composite end point, all-cause mortality, CV mortality, and LVAD implant.	∗Rhythm control was recommended
Oraii et al, 2024	Meta-analysis	CA (650) vs medical therapy (594)∗	1. Paroxysmal or persistent AF 2. NYHA II-IV, no specific LVEF criteria	HF events	1. CV death 2. All-cause mortality	CA superior to medical therapy in reducing HF events, cardiovascular death, and all-cause mortality.	∗Including rate or rate control.

Only gold members can continue reading. Log In or Register to continue

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Related

Related posts:

1. Atrial Fibrillation Ablation in Heart Failure with Preserved Ejection Fraction
2. Atrial Fibrillation Management with Guideline-Directed Medical Therapy and Comorbidity Treatment in Heart Failure Patients
3. Rate Versus Rhythm Control for Atrial Fibrillation with Heart Failure
4. Atrial Fibrillation in End-Stage Heart Failure

Stay updated, free articles. Join our Telegram channel

Join