ATRIAL FIBRILLATION ABLATION – BENEFITS BEYOND SYMPTOM REDUCTION WITH A FOCUS ON PATIENTS WITH HEART FAILURE WITH REDUCED EJECTION FRACTION Authors: Norbert Guettler , Kim Rajappan , Edward Nicol European Journal of Arrhythmia & Electrophysiology. 2019;5(1):30-8 DOI: https://doi.org/10.17925/EJ AE.2019.5.1.30 Abstract Catheter ablation for atrial fibrillation (AF) has been regarded as a means for symptom control in patients with AF who are resistant to medical therapy. Recommendations in past USA and European guidelines for the management of patients with AF are based on that strategy. However, there are emerging data that catheter ablation for AF may have additional prognostic benefits for patients with AF beyond symptom reduction. Favourable effects of AF ablation on stroke, dementia and other outcomes have been reported. Recently, there has been growing evidence about AF ablation benefits in patients with AF and heart failure with reduced ejection fraction (HFrEF). In this article, seven randomised controlled trials, observational trials, as well as meta-analyses and reviews are described for AF ablation in patients with HFrEF. The results of these trials suggest that AF ablation has beneficial effects on all-cause mortality, hospitalisation for heart failure, improvement of left ventricular ejection fraction, quality of life, and functional capacity. These findings led to additional recommendations in a focused update of the USA guidelines for the management of patients with AF. Data on AF ablation in the subgroups of patients with heart failure with mid-range ejection fraction and preserved ejection fraction, however, are sparse. Robust randomised controlled trials on prognostic benefits of AF ablation in these subgroups are still needed to inform clinical practice. Keywords Atrial fibrillation, catheter ablation, prognostic benefits, heart failure with reduced ejection fraction Disclosure Norbert Guettler, Kim Rajappan and Edward Nicol have nothing to disclose in relation to this article. Compliance with Ethics This study involves a review of the literature and did not involve any studies with human or animal subjects performed by any of the authors. Review Process Double-blind peer review. Authorship The named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship of this manuscript, take responsibility for the integrity of the work as a whole, and have given final approval for the version to be published. Received April 07, 2019 Accepted 29 May 2019 Published Online July 22, 2019 Correspondence Norbert Guettler, Air Force Centre of Aerospace Medicine, Strasse der Luftwaffe 322, 82256 Fuerstenfeldbruck, Germany. E: [email protected] Support No funding was received for the publication of this article. Download PDF Bookmark & Add to Profile Order reprints Get Permission Catheter ablation for atrial fibrillation (AF) is now a widely established treatment to prevent AF recurrence. Catheter ablation usually involves the isolation of the pulmonary veins, which is an adequate strategy in the majority of cases with paroxysmal AF. Persistent AF, however, often requires additional substrate modification.1–3 Several strategies of substrate modification are under evaluation. While complex fractionated atrial electrograms and linear lesions have been abandoned as a consequence of the STAR AF II (Substrate and Trigger Ablation for Reduction of Atrial Fibrillation Trial-Part II) results,4 the ablation of fibrotic areas, posterior wall isolation, and the ablation of non-pulmonary vein triggers show more promising results. The ablation results of rotational activity are still contradictory.3 In many clinical trials, catheter ablation has proven superior over antiarrhythmic drug therapy for the maintenance of sinus rhythm and the improvement of quality of life.5–7 In the latest guidelines for the management of AF, the European Society of Cardiology recommends catheter ablation in patients with symptomatic recurrences of AF on antiarrhythmic drug therapy for paroxysmal AF (class I, level of evidence A), and persistent AF (class IIa, level of evidence C).8 In selected patients it should be considered as a first-line therapy to prevent recurrent AF to improve symptoms as an alternative to antiarrhythmic drug therapy, considering patient choice, benefit, and risk (class IIa, level of evidence B recommendation). Similar recommendations are given by the American Heart Association (AHA), the American College of Cardiology (ACC), and the Heart Rhythm Society (HRS) in their 2014 guidelines.9 Beyond improvement of symptoms and quality of life, several recent studies have demonstrated the prognostic benefit of catheter ablation for certain patient groups including reduced mortality and a reduction in hospitalisation. As a result of these trials, AHA, ACC and HRS added the recommendation in their 2019 focused update (of the 2014 guideline) that AF catheter ablation may be reasonable in selected patients with symptomatic AF and heart failure with reduced ejection fraction (HFrEF), to potentially lower mortality rates and reduce hospitalisation for heart failure (HF).10 In this article, recent clinical trials, meta-analyses, and reviews will be analysed to address whether catheter ablation for AF can have a prognostic benefit beyond symptom reduction in patients with HF. Different results for variable patient groups will be highlighted.
