1. N Engl J Med. 2018 Feb 1;378(5):417-427. doi: 10.1056/NEJMoa1707855.

Catheter Ablation for Atrial Fibrillation with Heart Failure.

Marrouche NF(1), Brachmann J(1), Andresen D(1), Siebels J(1), Boersma L(1),
Jordaens L(1), Merkely B(1), Pokushalov E(1), Sanders P(1), Proff J(1), Schunkert
H(1), Christ H(1), Vogt J(1), Bänsch D(1); CASTLE-AF Investigators.

Collaborators: Ince H, Nölker G, Popov S, Szumowski L, Lebedev D, Szili-Török T, 
Martin P, Ivanitskiy E, Zrenner B, Chow A, Elvan A, Diaz Remirez I, Pezawas T,
Schmidinger H, Busch M, Csanádi Z, Haverkamp W, Pürerfellner H, Schärtl A, Lemke 
B, Schlüter S, Deisenhofer I, Günther J, Lawrenz T, Vester EG, Wiedemann M,
Marrouche NF, Wenzel B, Camm J, Aliot E, Lehmacher W, Wieneke H, Braunschweig F, 
Verwey HF.

Author information: 
(1)From the Comprehensive Arrhythmia Research and Management Center, Division of 
Cardiovascular Medicine, School of Medicine, University of Utah Health, Salt Lake
City (N.F.M.); Klinikum Coburg, Coburg (J.B.), Kardiologie an den Ev.
Elisabeth-Kliniken (D.A.) and Biotronik (J.P., H.S.), Berlin, Klinik Rotes Kreuz,
Frankfurt/Main (J.S.), Klinikum Links der Weser, Bremen (L.B.), Deutsches
Herzzentrum München, Munich (H.C.), Institute of Medical Statistics and
Computational Biology, Cologne (D.B.), and KMG Klinikum, Güstrow (J.V.) - all in 
Germany; Antonius Ziekenhuis Nieuwegein, Nieuwegein (L.J.), and the Erasmus
University Medical Center, Rotterdam (B.M.) - both in the Netherlands; Semmelweis
Medical University, Budapest, Hungary (E.P.); and the State Research Institute of
Circulation Pathology, Novosibirsk, Russia (P.S.).

Comment in
    N Engl J Med. 2018 Feb 1;378(5):468-469.
    N Engl J Med. 2018 Aug 02;379(5):490.
    N Engl J Med. 2018 Aug 02;379(5):490.
    N Engl J Med. 2018 Aug 02;379(5):491-2.

BACKGROUND: Mortality and morbidity are higher among patients with atrial
fibrillation and heart failure than among those with heart failure alone.
Catheter ablation for atrial fibrillation has been proposed as a means of
improving outcomes among patients with heart failure who are otherwise receiving 
appropriate treatment.
METHODS: We randomly assigned patients with symptomatic paroxysmal or persistent 
atrial fibrillation who did not have a response to antiarrhythmic drugs, had
unacceptable side effects, or were unwilling to take these drugs to undergo
either catheter ablation (179 patients) or medical therapy (rate or rhythm
control) (184 patients) for atrial fibrillation in addition to guidelines-based
therapy for heart failure. All the patients had New York Heart Association class 
II, III, or IV heart failure, a left ventricular ejection fraction of 35% or
less, and an implanted defibrillator. The primary end point was a composite of
death from any cause or hospitalization for worsening heart failure.
RESULTS: After a median follow-up of 37.8 months, the primary composite end point
occurred in significantly fewer patients in the ablation group than in the
medical-therapy group (51 patients [28.5%] vs. 82 patients [44.6%]; hazard ratio,
0.62; 95% confidence interval [CI], 0.43 to 0.87; P=0.007). Significantly fewer
patients in the ablation group died from any cause (24 [13.4%] vs. 46 [25.0%];
hazard ratio, 0.53; 95% CI, 0.32 to 0.86; P=0.01), were hospitalized for
worsening heart failure (37 [20.7%] vs. 66 [35.9%]; hazard ratio, 0.56; 95% CI,
0.37 to 0.83; P=0.004), or died from cardiovascular causes (20 [11.2%] vs. 41
[22.3%]; hazard ratio, 0.49; 95% CI, 0.29 to 0.84; P=0.009).
CONCLUSIONS: Catheter ablation for atrial fibrillation in patients with heart
failure was associated with a significantly lower rate of a composite end point
of death from any cause or hospitalization for worsening heart failure than was
medical therapy. (Funded by Biotronik; CASTLE-AF ClinicalTrials.gov number,
NCT00643188 .).

DOI: 10.1056/NEJMoa1707855 
PMID: 29385358  [Indexed for MEDLINE]