Is there a CASTLE-AF on the hill?

Extract

Additional evidence supporting atrial fibrillation ablation in patients with symptomatic atrial fibrillation and heart failure 

Atrial fibrillation (AF) is common in patients with heart failure and is associated with a worse outcome. Previous studies of rhythm control using antiarrhythmic drugs have not shown any prognostic benefit in AF.^1,2 Even in patients with heart failure, the large Atrial Fibrillation Congestive heart failure trial failed to show a benefit of amiodarone despite a marked reduction in AF burden.³ It has been suggested that antiarrhythmic drugs alone may not be powerful enough to maintain sinus rhythm, particularly in heart failure, or that the beneficial effects of sinus rhythm in this group are balanced by the adverse effects of antiarrhythmic drugs.

Ablation offers a powerful treatment to restore sinus rhythm and reduce recurrent AF without requiring long-term therapy, and with synergistic effects on top of antiarrhythmic drugs. Early studies suggested improved exercise tolerance with AF ablation in patients with heart failure.⁴ The PABA-CHF pilot trial in 2008 compared pulmonary vein isolation with AV node ablation and biventricular pacing in patients with AF and severe heart failure. Ablation led to greater improvements in exercise tolerance, ejection, and symptoms.⁵ More recently, the AATAC study comparing ablation with amiodarone in persistent AF confirmed these findings and also appeared to show reduced mortality in the ablation group.⁶