ESC Congress 2017 In Review – Focus on Arrhythmias - 7

Late-Breaking Clinical Trials

ESC Congress 2017

In Review

Arrhythmias

Catheter Ablation of Atrial Fibrillation Improves Mortality and
Disease Progression in Patients
With Heart Failure
Written by Maria Vinall

Nassir F. Marrouche, MD, University of Utah, Salt
Lake City, Utah, USA, presented the CASTLE-AF trial
[NCT00643188], which showed that catheter ablation
of atrial fibrillation (AF) in patients with heart failure
(HF) is associated with improved all-cause mortality, cardiovascular mortality, and fewer admissions for
worsening HF and hospitalisation, compared with conventional standard of care treatment.
Patients with HF and AF have an increased risk of
morbidity and mortality, compared with HF patients
with no AF. The CASTLE-AF trial was designed to study
the effectiveness of catheter ablation in improving mortality as well as HF progression in patients with HF and
AF compared with standard care.
CASTLE-AF was a prospective, multicentre (31 sites;
9 countries), randomised, controlled trial. A total of 363
patients were enrolled (179 received ablation; 184 conventional therapy). The study included patients with
symptomatic paroxysmal or persistent AF, left ventricular ejection fraction (LVEF) ≤ 35%, and NYHA class ≥ II
who had failed or shown intolerance to ≥ 1 antiarrhythmic drug (AAD) or were unwilling to take an AAD, and
who had a cardioverter defibrillator with automatic daily
home-monitoring capabilities already implanted. The
primary endpoint was the composite of all-cause mortality and unplanned hospitalisation for worsening HF.
Conventional treatment was according to the ACC/AHA/
ESC 2006 Guidelines for the Management of Patients
With Atrial Fibrillation [Fuster V et al. Circulation. 2006].
Efforts were made to maintain sinus rhythm.
Anticoagulation was initiated and maintained throughout the study. An INR between 2.0 and 3.0 was maintained. The ablation protocol consisted of pulmonary
vein isolation with additional lesions at the discretion of
operator and repeat ablation after a blanking period.
Participants were a mean age of 64 years; median
LVEF was about 32%; 86.1% were men. Most subjects
had persistent AF (70% in the ablation group; 65% in
the conventional group). More than half of the subjects
were NYHA class II (58% vs 61%, ablation and conven-

tional group), about 28% were class III, and 1% to 2%
were class IV. Implantable cardioverter defibrillators
(ICD) were present in 73% of patients in the ablation
group and 72% in the conventional group. The remaining patients had a cardiac resynchronisation therapy
defibrillator (CRT-D) device. More than 90% of patients
were being treated with either an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker,
ß-blocker, diuretic, or oral anticoagulant.
The absolute change in LVEF from baseline was significantly higher in the ablation arm versus conventional care at 12, 36, and 60 months. The primary endpoint,
a composite of all-cause mortality and unplanned hospitalisation for worsening HF, was significantly improved
for the ablation group (risk reduction [RR] compared
with conventional treatment, 38%; P = .007). All-cause
mortality was significantly reduced in the ablation
group (RR, 47%; P = .011), as were admissions for worsening HF (RR, 44%; P = .004), cardiovascular mortality
risk (RR, 51%; P = .009), and cardiovascular hospitalisation (RR, 28%; P = .041).
In this study, catheter ablation of AF was associated
with improved mortality and HF hospitalisation when
compared with conventional treatment in patients with
HF and AF.

Multilevel Educational
Intervention Significantly
Increases the Proportion of
Atrial Fibrillation Patients
Treated With Anticoagulation
Written by Phil Vinall

Oral anticoagulation (OAC) is underused in patients
with atrial fibrillation (AF). Christopher B. Granger,
MD, Duke University Medical Center, Durham, North
Carolina, USA, presented data from the IMPACT-AF trial

Official Peer-Reviewed Highlights From ESC Congress 2017

Table of Contents for the Digital Edition of ESC Congress 2017 In Review – Focus on Arrhythmias