Catheter Ablation in End-Stage Heart Failure with Atrial Fibrillation

The CASTLE-HTx trial evaluated catheter ablation plus medical therapy versus medical therapy alone in patients with symptomatic atrial fibrillation and end-stage heart failure referred for heart transplantation. Conducted in Germany, the single-center, open-label, randomized study assigned 194 patients (97 per group). The trial was terminated early due to clear benefit favoring ablation. At median 18-month follow-up, primary endpoint death, urgent transplant, or LVAD occurred in 8% of ablation patients vs. 30% in controls (HR 0.24; P<0.001). All-cause mortality was 6% vs. 20% (HR 0.29). LVAD implantation rates were 1% vs. 10%; urgent transplant: 1% vs. 6%. Ablation improved LVEF (+6.4% at 12 months) and reduced AF burden (–22.7% at 12 months), with 56% of ablation patients event-free and not in persistent AF at 1 year. Procedure-related complications were minimal. The trial supports ablation as a life-extending strategy in advanced heart failure with symptomatic AF, though multicenter validation is warranted.

The CASTLE-HTx trial evaluated catheter ablation plus medical therapy versus medical therapy alone in patients with symptomatic atrial fibrillation and end-stage heart failure referred for heart transplantation. Conducted in Germany, the single-center, open-label, randomized study assigned 194 patients (97 per group). The trial was terminated early due to clear benefit favoring ablation. At median 18-month follow-up, primary endpoint death, urgent transplant, or LVAD occurred in 8% of ablation patients vs. 30% in controls (HR 0.24; P<0.001). All-cause mortality was 6% vs. 20% (HR 0.29). LVAD implantation rates were 1% vs. 10%; urgent transplant: 1% vs. 6%. Ablation improved LVEF (+6.4% at 12 months) and reduced AF burden (–22.7% at 12 months), with 56% of ablation patients event-free and not in persistent AF at 1 year. Procedure-related complications were minimal. The trial supports ablation as a life-extending strategy in advanced heart failure with symptomatic AF, though multicenter validation is warranted.