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Catheter ablation of atrial fibrillation shown to reduce mortality and hospitalisations in heart failure patients

Arrhythmias and Device Therapy

Marrouche.jpgCatheter ablation of atrial fibrillation was associated with improvement in all-cause mortality and fewer worsening heart failure admissions in comparison to conventional treatment of heart failure, a trial— CASTLE AF—presented at yesterday’s Hot Line: Late-Breaking Clinical Trials 1 has found. 

“The CASTLE-AF trial is novel because it is the first time mortality and hospitalisation have been used as an endpoint,” Professor Carina Blomstrom-Lundqvist (Uppsala University, Uppsala, Sweden), commented in a discussant review of the study. The results, presented yesterday by Doctor Nassir Marrouche (University of Utah Health Care, Salt Lake City, USA), indeed demonstrated a link between catheter ablation of atrial fibrillation (AF) and improved rates of all-cause mortality and worsening heart failure hospitalisation—the combined endpoint of the trial. 

“AF and heart failure are well intertwined,” Dr. Marrouche explained. “Catheter ablation of AF in patients with heart failure has been shown feasible.” Aiming to build on this, the team sought to assess the effectiveness of catheter ablation for AF in heart failure patients. 

Three hundred and ninety-seven patients with symptomatic paroxysmal or persistent AF were enrolled and randomised following eligibility assessment of 3,013 patients. Following exclusions during a five-week run-in period, and patient crossover between the two groups, a final total of 153 patients were treated with catheter ablation and 184 with conventional treatment. In addition to the primary endpoints, the team recorded secondary endpoints including cardiovascular (CV) mortality, and CV-related hospitalisation. Patients were followed-up from three to 60 months. 

The conventional arm was treated according to the ACC/AHA/ ESC 2006 guidelines for the treatment of AF in heart failure. The ablation arm underwent pulmonary vein isolation, with additional lesions ablated at the discretion of the operator. Following a blanking period, ablation was repeated. 

When evaluating the effectiveness of catheter ablation according to the composite primary endpoint, the team observed a risk reduction of 38% from baseline at 60 months, statistically significant in comparison to the conventional group (p=0.007). Individually, the risk of worsening heart failure admission was reduced by 44% from baseline in the catheter ablation group, and all-cause mortality risk was reduced by 47% in this group. Both results were statistically significant in comparison to conventional treatment (p=0.004; p=0.011, respectively). 

The secondary endpoints of CV mortality and CV hospitalisation also revealed statistically significant risk reductions for catheter ablation in comparison to conventional treatment. Cardiovascular mortality risk was reduced by 51% (p=0.008) and cardiovascular hospitalisation risk by 28% (p=0.05). 

Concluding, Dr. Marrouche explained, “Catheter ablation led to significant improvement in the primary composite endpoint of all-cause mortality and worsening heart failure admissions.” 

“The take-home message of this trial is that it is time to offer catheter ablation procedures at an early stage in heart failure patients with AF,” she added. “But, we must be careful to select patients that reflect the populations included in this trial.”

Resources of the presentation: Catheter ablation versus standard conventional treatment in patients with left ventricular dysfunction and atrial fibrillation: the CASTLE-AF trial

Click here to read other scientific highlights in the full edition of the Congress news.