Background: Rhythm control with medical therapy has been shown to not be superior to rate control for patients with both heart failure and AF. Rhythm control by ablation has been associated with positive outcomes in this same population, but its effectiveness, compared with medical therapy for patient-centered outcomes, has not been demonstrated.
Study design: Multicenter, open-label, randomized, controlled superiority trial.
Setting: 33 hospitals from Europe, Australia, and the United States during 2008-2016.
Synopsis: A total of 363 patients with HF with LVEF less than 35%, New York Heart Association II-IV symptoms, and permanent or paroxysmal AF who had previously failed or declined antiarrhythmic medications were randomly assigned to undergo ablation by pulmonary vein isolation or to medical therapy. The primary outcome – a composite of death or hospitalization for heart failure – was significantly lower in the ablation group, compared with the medical therapy group (28.5% vs. 44.6%; P = .006) with a number needed to treat of 8.3. The secondary outcomes of all-cause mortality and heart failure admissions were also significantly lower in the ablation group (13.4% vs. 25%; P = .01 and 20.7% vs. 35.9%; P = .004 respectively). The burden of AF, as identified by patient implantable devices was significantly lower in the ablation group, suggesting the likely mechanism of ablation benefit. Limitations of this study include its small sample size and lack of physician or patient blinding to treatment assignment.
Bottom line: Compared with medical therapy, catheter ablation of atrial fibrillation for patients with symptomatic heart failure with LVEF less than 35% was associated with significantly decreased mortality and heart failure admissions.
Citation: Marrouche N et al. Catheter ablation for atrial fibrillation with heart failure. N Eng J Med. 2018 Feb 1; 378:417-27.
Dr. Salber is a hospitalist at Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.
