A comparison of medical therapy and ablation for atrial fibrillation in patients with heart failure

ABSTRACT

Introduction

Atrial fibrillation and heart failure frequently co-exist and the combination is associated with a worse prognosis than either condition alone. A number of pharmacological agents and invasive procedures have been shown to benefit this complex patient group.

Objective

In this review, we compare different therapeutic approaches to atrial fibrillation and heart failure, including pharmacotherapy, left atrial catheter ablation and pace-and-ablate.

Expert opinion

Left atrial catheter ablation is an efficacious option for restoring sinus rhythm and is most likely to provide benefit to those in whom durable sinus rhythm can be expected, and whose life expectancy is not significantly reduced by other pathologies or advanced age. A pace-and-ablate approach, particularly with physiological pacing, may provide more benefit to those with low chance of maintaining sinus rhythm. Both invasive options generally outperform pharmacotherapy, although it is important to individualize the approach for each patient through shared decision-making.

KEYWORDS:

• Atrial fibrillation
• atrioventricular node ablation
• catheter ablation
• heart failure with reduced ejection fraction
• heart failure with preserved ejection fraction
• pulmonary vein isolation
• rate control
• rhythm control

Article highlights

• Atrial fibrillation and heart failure are interlinked conditions, which share common risk factors and both contribute to adverse cardiac remodelling

• Restoration of sinus rhythm with left atrial catheter ablation is more effective than with anti-arrhythmic drugs, avoids long-term drug side effects, and improves quality of life

• In those with low likelihood of durable sinus rhythm, or poor life expectancy due to advanced age or other comorbidities, pace-and-ablate is a better option than left atrial ablation

• Shared decision-making and individualized care are critical to determining the best approach for any given patient

Declaration of interest

D Gupta has received institutional research grants from Biosense Webster, Boston Scientific and Medtronic. Speaker fees from Boston Scientific.

M Kahn has received honoraria for Medtronic Advisory board. Speaker fees from AZ and Novartis

GYH Lip is a consultant and speaker for BMS/Pfizer, Boehringer Ingelheim and Daiichi-Sankyo. No fees are received personally. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.