Catheter Ablation for Atrial Fibrillation in Heart Failure — An Option to Defer Transplantation?

This NEJM editorial assesses the CASTLE-HTx trial, which examined catheter ablation for atrial fibrillation in patients with advanced heart failure (NYHA class II–IV, LVEF ≤35%) eligible for heart transplantation. In this single-center study, 194 patients were randomized to receive either ablation plus guideline-directed medical therapy or medical therapy alone. The ablation group showed significantly lower incidence of the composite endpoint death, urgent transplant, or LVAD implantation (HR 0.24). Procedural complications were rare (4 patients). Improvements included reduced AF burden (–22.7 percentage points) and increased LVEF (+6.4 percentage points). However, interpretation is limited by single-center enrollment, small sample size, selective recruitment, and incomplete reporting of quality-of-life and functional endpoints. About 21% of referred patients were randomized, and crossover occurred in both directions. The editorial calls for multicenter validation and registries to investigate whether ablation may delay the need for transplantation or mechanical support in end-stage heart failure.

This NEJM editorial assesses the CASTLE-HTx trial, which examined catheter ablation for atrial fibrillation in patients with advanced heart failure (NYHA class II–IV, LVEF ≤35%) eligible for heart transplantation. In this single-center study, 194 patients were randomized to receive either ablation plus guideline-directed medical therapy or medical therapy alone. The ablation group showed significantly lower incidence of the composite endpoint death, urgent transplant, or LVAD implantation (HR 0.24). Procedural complications were rare (4 patients). Improvements included reduced AF burden (–22.7 percentage points) and increased LVEF (+6.4 percentage points). However, interpretation is limited by single-center enrollment, small sample size, selective recruitment, and incomplete reporting of quality-of-life and functional endpoints. About 21% of referred patients were randomized, and crossover occurred in both directions. The editorial calls for multicenter validation and registries to investigate whether ablation may delay the need for transplantation or mechanical support in end-stage heart failure.