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2024 AF Symposium
The Benefits of Ablation Across the AF Spectrum: From Early Intervention to Late-Stage Heart Failure: Part III
This important Friday session had five speakers: Dr. Stephen Willems, Dr. Jason Andrade, Dr. Philipp Sommer, Dr. Douglas Packer and Dr. Francis Marchlinski. –
Dr. Philipp Sommer of the University of Bochum, Bad Oeynhausen, Germany, gave the third talk in what was described as the “most important session of the whole meeting.”
AF Ablation in Patients with Advanced Heart Failure: CASTLE-HTx Study
Dr. Philipp Sommer
Dr. Sommer’s presentation could be considered a continuation of or an addition to the CASTLE-AF trial discussed in the 2018 AF Symposium.
As I wrote then, “the findings of the CASTLE AF clinical trial are one of the most important studies for patients in the last decade.” (See Live Longer―Have a Catheter Ablation.)
“If you look at the lectures [in this session], every one of them is Guideline changing This is the most important session of the whole [Symposium] meeting.”—Dr. Nassir Marrouche
All A-Fib patients in CASTLE AF had sick hearts and advanced heart failure (their ejection fractions were less than 35%). They all had ICDs (Implantable Cardioverter Defibrillators).
Patients received either RF catheter ablation or conventional drug therapy. The median follow-up was over 3 years (37.8 months).
Ablation Improves Not Just Quality but Quantity of Life (How Long One Lives)
Key results of the CASTLE AF trial were:
• 47% lower death rate in the catheter ablation group vs conventional therapy;
• 60% of the ablation group improved their ejection fraction by more than 35% thereby curing a major component of heart failure;
• 60% of the ablation group were in normal sinus rhythm after 5 years, compared to only 22% receiving conventional drug therapy;
• 51% reduction in cardiovascular mortality in the ablation group;
• Stroke rate of the ablation group was 50% of the conventional drug treatment group (even though 94% of the patients were taking Coumadin);
• 38% reduction in all-cause mortality and hospital admissions in the ablation group. A-Fib burden (percentage of time in A-Fib) also reduced;
• Heart failure hospital admissions in the ablation group reduced within 6 months of the ablation.
Ablate Heart Failure Patients as Early As Possible
Principal author of CASTLE AF, Dr. Nassir Marrouche, stressed that catheter ablation for A-Fib patients with heart failure should be performed early, the earlier the better, “…Ablate them early on, very soon in the disease stage.”
“Abate A-Fib patients with heart failure early, the earlier the better.”—Dr. Marrouche
Dr. Sommer’s CASTLE-HTx Study
The CASTLE-HTx study was conducted at the University of Bochum, Bad Oeynhausen, Germany, which is one of the leading heart failure centers in Europe. [For example, they do 100+ heart transplants a year].
Dr. Sommer’s CASTLE-HTx study can be considered a continuation of CASTLE AF.
When Is It Too Late for a Catheter Ablation?
Dr. Sommer asked, even though it’s obvious from CASTLE AF that catheter ablation is superior to standard medical therapy, “How sick is too sick, when is it too late for a catheter ablation?” In one study he cited, end stage heart failure (congestive heart failure) was a risk factor for mortality at 30 days. 43% of end stage heart failure patients were too late to get any benefit from catheter ablation.
Dr. Sommer’s Study
Dr. Sommer and his colleagues did their own study of heart failure patients with a follow-up of 3 years. They compared catheter ablation to medical therapy [1/2 were on the dreaded amiodarone].
In one year, ejection fraction was improved by 8% in the ablation group, A-Fib burden was reduced by 50%, A-Fib progression was stopped and surprisingly regressed even though 70% of their patients were in persistent A-Fib. T
They were able to reduce the amiodarone dosage from 45% to 25%. Ablation improved left ventricular function which decreased A-Fib burden. Catheter Ablation was associated with a lower likelihood of death by a reduction in all-cause mortality. “Catheter ablation produced a regression in the end-stage heart failure population.”
To read other presentations in this series, go to My Summary Reports Written for Atrial Fibrillation Patients.
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