Atrial fibrillation ablation in heart failure

Abstract

Atrial fibrillation (AF) and heart failure (HF) commonly coexist in the same patient and either condition predisposes to the other. Several mechanisms promote the pathophysiological relationship between AF and HF, reducing quality of life, increasing the risk of stroke, and worsening HF progression. Although restoration and maintenance of sinus rhythm would be ideal for those patients, several trials comparing rhythm and rate control failed to show a benefit of rhythm control strategy, achieved with pharmacological therapy, in terms of hospitalization for HF or death. Catheter ablation is a well-established option for symptomatic AF patients, resistant to drug therapy, with normal cardiac function. Several recent studies have shown an improvement in clinical outcomes after AF ablation in HF patients highlighting the emerging role of the invasive approach in this subset of patients. However, several concerns regarding patients’ selection and standardization of the procedure still remain to be addressed.

Timely and individualized heart failure management: need for implementation into the new guidelines

“…Although restoration and maintenance of sinus rhythm would be ideal for these patients, several studies comparing rhythm and rate control have failed to show any advantage of rhythm control achieved with pharmacological therapy in terms of HF hospitalization or death [ 37 , 38 ]. Catheter ablation is an established therapy for symptomatic AF patients who do not respond to medical therapy and have normal cardiac function [ 38 , 39 ]. Furthermore, early rhythm-control therapy has been associated with a lower risk of adverse CV outcomes than usual care among patients with a history of CV disease within the first year of AF diagnosis [ 40 ].…”

“…Furthermore, early rhythm-control therapy has been associated with a lower risk of adverse CV outcomes than usual care among patients with a history of CV disease within the first year of AF diagnosis [ 40 ]. Several recent studies have shown improvement in clinical outcomes after AF ablation in HF patients, highlighting the growing importance of the invasive approach in this patient population [ 39 ]. The recent Catheter Ablation vs. Standard Conventional Therapy in Patients with Left Ventricular Dysfunction (CASTLE-AF) trial was the first randomized trial investigating the impact of AF catheter ablation compared with medical therapy (rate or rhythm control) on mortality and hospitalizations in patients with HF.…”

“…A significant reduction in the composite endpoint of death and HF hospitalization was shown in the catheter ablation group compared with the medical therapy one [ 39 ]. More recently, the Catheter Ablation vs. Medical Rate Control in Atrial Fibrillation and Systolic Dysfunction (CAMERA-MRI) trial randomized patients with idiopathic cardiomyopathy and persistent AF who underwent CMR to either catheter ablation or rate control therapy [ 39 ]. There was a significant improvement in LVEF in patients who underwent catheter ablation compared with those who were randomized to drug therapy despite optimal rate control.…”

“…Patients with no evidence of late gadolinium enhancement (LGE) on CMR had better improvements in their LV function after the ablation compared with those who had LGE. This result showed that CMR might be a strong tool to identify HF patients who may benefit more from catheter ablation [ 39 ]. However, the AMICA trial (Atrial Fibrillation Management in Congestive Heart Failure With Ablation) did not reveal any benefit of catheter ablation in patients with persistent AF and EF < 35.…”

Neue Therapiekonzepte der HfrEF

“…Mehrere Mechanismen fördern die pathophysiologische Beziehung zwischen VHF und HI, indem sie die Lebensqualität verringern, das Schlaganfallrisiko erhöhen und das Fortschreiten der HI verschlimmern [26]. Obwohl die Wiederherstellung und Aufrechterhaltung des Sinusrhythmus für diese Patienten ideal wären, konnten mehrere Studien, die Rhythmus-und Frequenzkontrolle verglichen, keinen Vorteil der Strategie der Rhythmuskontrolle, die mit pharmakologischer Therapie erreicht wird, in Bezug auf HI-Hospitalisierung oder Tod zeigen [27]. Die Katheterablation ist eine etablierte Option für symptomatische VHF-Patienten.…”