Atrial fibrillation ablation as first-line therapy for patients with heart failure with reduced ejection fraction (HFrEF): evaluating the impact on patient survival

ABSTRACT

Introduction

Atrial fibrillation and congestive heart failure share several pathophysiological mechanisms. As a result of their association, patients have worse outcomes than if either condition were present alone.

Areas covered

While multiple trials report no significant difference between the use of pharmacological rhythm control and the use of rate control in terms of mortality and morbidity in patients with HFrEF, there is evidence to suggest that catheter ablation is beneficial in this patient population. The present review aims to provide a comprehensive overview of catheter ablation as a treatment modality for atrial fibrillation in patients with HFrEF as well as evaluate its outcome on survival.

Expert opinion

An appropriate patient selection strategy for patients with HFrEF could be the next step in determining which patients might benefit most from catheter ablation. Future atrial fibrillation management may incorporate digital health and pulsed-field ablation.

KEYWORDS:

• Atrial fibrillation
• catheter ablation
• mortality
• survival
• heart failure with reduced ejection fraction

Article highlights

• AF begets HF and vice versa

• No superiority of pharmacologic rhythm control over rate control in patients with HFrEF and AF in terms of mortality and morbidity

• Many trials showed the efficacy of catheter ablation in treating patients with HFrEF and AF in terms of survival

• Several criteria outlined in the current review article help delineate which patients are better suited to catheter ablation.

Abbreviations

AATAC, Ablation Versus Amiodarone for Treatment of Persistent Atrial Fibrillation in Patients With Congestive Heart Failure and an Implanted Device; ARC-HF, A Randomised Trial to Assess Catheter Ablation Versus Rate Control in the Management of Persistent Atrial Fibrillation in Chronic Heart Failure; CAMERA-MRI, Catheter Ablation Versus Medical Rate Control in Atrial Fibrillation and Systolic Dysfunction; CAMTAF, Catheter Ablation Versus Medical Treatment of AF in Heart Failure; CASTLE-AF, Catheter Ablation for Atrial Fibrillation With Heart Failure; PABA-CHF, The Pulmonary vein antrum isolation vs AV node ablation with Bi-ventricular pacing for treatment of Atrial fibrillation in patients with Congestive Heart Failure; CONTRA-HF, Ablation of Atrial Fibrillation in Heart Failure Patients; RACE-8-HF, Cryoballoon Ablation Versus Medical Therapy in Patients With Heart Failure and Atrial Fibrillation; RAFT-AF, Rhythm Control: Catheter Ablation With or Without Anti-Arrhythmic Drug Control of Maintaining Sinus Rhythm Versus Rate Control With Medical Therapy and/ or Atrio-Ventricular Junction Ablation and Pacemaker Treatment for Atrial Fibrillation; CMR, cardiac magnetic resonance; ICD, implantable cardioverter-defibrillator; NYHA, New York Heart Association; HR, hazard ratio; PVI, pulmonary vein isolation; 6MWD, 6 minute walk distance; MLWH, Minnesota Living with Heart Failure; ACEi, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker.

Declaration of interest

Dr. Marrouche reports receiving grant support and consulting fees from Abbott, Medtronic, Biosense Webster, Boston Scientific, and Siemens, receiving consulting fees from Preventice, and holding equity Cardiac Design. All other authors have no 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. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer Disclosures

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

Additional information

Funding

This paper was not funded.