ABC | Volume 110, Nº4, April 2018

Editorial Scanavacca & Bocchi Catheter ablation for atrial fibrillation in patients with heart failure Arq Bras Cardiol. 2018; 110(4):300-302 1. WangTJ,LarsonMG,LevyD,VasanRS,LeipEP,WolfPA,etal.Temporalrelations of atrial fibrillation and congestive heart failure and their joint influence on mortality: the FraminghamHeart Study. Circulation 2003;107(23):2920–5. 2. Santhanakrishnan R, Wang N, Larson MG, Magnani JW, McManus DD, Lubitz SA, et al. Atrial fibrillation begets heart failure and vice versa: temporal associations and differences in preserved versus reduced ejection fraction. Circulation. 2016;133(5):484-92. 3. Luong C, Barnes ME, Tsang TS. Atrial fibrillation and heart failure: cause or effect ? Curr Heart Fail Rep. 2014;11(4):463-70. 4. Wyse DG, Waldo AL, DiMarco JP, Domanski MJ, Rosenberg Y, Schron EB, et al; Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med. 2002;347(23):1825-33. 5. Torp-Pedersen C, Møller M, Bloch-Thomsen PE, Køber L, Sandøe E, Egstrup K, et al. Dofetilide in patients with congestive heart failure and left ventricular dysfunction. N Engl J Med. 1999;341(12):857-65. 6. Roy D, TalajicM, Nattel S, Wyse DG, Dorian P, Lee KL, et al; Atrial Fibrillation andCongestiveHeartFailureInvestigators.Rhythmcontrolversusratecontrol for atrial fibrillation and heart failure. N Engl J Med. 2008;358(25):2667-77. 7. Santos SN, Henz BD, Zanatta AR, Barreto JR, Loureiro KB, Novakoski C, et al. Impact of atrial fibrillation ablation on left ventricular filling pressure and left atrialremodeling. Arq Bras Cardiol. 2014;103(6):485-92. 8. Lobo TJ, Pachon CT, Pachon JC, Pachon EI, Pachon MZ, Pachon JC, et al. Atrial fibrillation ablation in systolic dysfunction: clinical and echocardiographic outcomes. Arq Bras Cardiol. 2015;104(1):45-52. 9. Hunter RJ, Berriman TJ, Diab I, Kamdar R, Richmond L, Baker V, et al. A randomized controlled trial of catheter ablation versus medical treatment of atrial fibrillation in heart failure (the CAMTAF trial). Circ Arrhythm Electrophysiol. 2014;7(1):31-8. 10. Di Biase L, Mohanty P, Mohanty S, Santangeli P, Trivedi C, Lakkireddy D, et al. Ablation versus amiodarone for treatment of persistent atrial fibrillation in patientswithcongestiveheartfailureandan implanteddevice:resultsfromthe AATACMulticenter Randomized Trial. Circulation. 2016;133(17):1637-44. 11. Marrouche NF, Brachmann J, Andresen D, Siebels J, Boersma L, Jordaens L, et al; CASTLE-AF Investigators. Catheter ablation for atrial fibrillation with heart failure. N Engl J Med. 2018;378(5):417-27. 12. Black-Maier E, Ren X, Steinberg BA, Green CL, Barnett AS, Rosa NS, et al. Catheter ablation of atrial fibrillation in patients with heart failure and preserved ejection fraction. Heart Rhythm. 2017 Dec 6. [Epub ahead of print]. 13. Machino-Ohtsuka T, Seo Y, Ishizu T, Sugano A, Atsumi A, Yamamoto M, et al. Efficacy, safety, and outcomes of catheter ablation of atrial fibrillation in patients with heart failurewith preserved ejection fraction. J AmColl Cardiol. 2013;62(20):1857-65. 14. Kheirkhahan M, Marrouche NF. It is time for catheter ablation to be considered a first-line treatment option in patients with atrial fibrillation and heart failure. Heart Rhythm. 2018 Feb 8. [Epub ahead of print]. 15. Calvo N, Bisbal F, Guiu E, Ramos P, Nadal M, Tolosana JM, et al. Impact of atrial fibrillation-induced tachycardiomyopathy in patients undergoing pulmonary vein isolation. Int J Cardiol. 2013;168(4):4093-7. References with very experienced operators. Also, inclusion criteria of patients to the CASTLE-AF trial included absence of response to (45-47%), unacceptable side effects from (12-14%), and unwillingness to take antiarrhythmic drugs (40-43%). In fact, in the CASTLE‑AF study the AF ablation was not tested in patients under acceptable rate control or rhythm control. So, new studies are needed to confirm such important observations. Benefits of catheter ablation of AF have also been suggested in a recent retrospective study evaluating HF patients with preserved ejection fraction HFpEF. 12 Two hundred-thirty AF patients with HF, 133 HFpEF and 97 patients with reduced ejection fraction (HFrEF) underwent catheter ablation. After a mean follow-up of 12 months, postablation outcomes as in-hospital adverse events, symptoms according to the Mayo AF Symptom Inventory (MAFSI), NYHA functional class, and freedom from atrial arrhythmia] were recorded. Ablation procedure (pulmonary vein isolation, pulmonary vein isolation with roof line, complex fractionated atrial electrograms), procedural time, fluoroscopy duration, and radiofrequency time were comparable between these groups. After ablation, the incidence of acute HF across these groups was similar. Both groups improved in MAFSI and NYHA functional class. Before ablation most of the patients were in NYHA functional class II, but after ablation the majority of patients shifted to class I from the more advanced classes. Preablation LVEF showed no correlation with freedom from atrial arrhythmia or repeat ablation rate. These results remained the same even after stratification based on AF phenotype. At 12 months postablation, all-cause hospitalization and cardiovascular hospitalization were similar for these patients. Also, previous study on AF ablation in HFpEF has suggested that AF can be effectively and safely treated with a composite of repeat procedures and pharmaceuticals. However, larger randomized controlled studies are also needed to confirm the benefits of AF ablation in HFpEF. 13 In conclusion, HF and AF are widely distributed diseases and difficult-to-treat conditions due to their synergistic effect. Once installed, a vicious circle is established, which significantly worsens the patient’s prognosis. No mortality or hard endpoint benefits have been demonstrated with the most commonly used antiarrhythmic drugs. Evidence has been generated in the last decade in favor of AF ablation in selected patients with AF with preserved or reduced LVEF. Based on these new data, catheter ablation has already been considered as first-line therapy in patients with paroxysmal or persistent AF and HF. 14 Evident benefit can be obtained in patients in which AF is the main cause for HF (tachycardiomyopathy). 15 However, we still need to develop new markers and tools to better define ideal ablation techniques and candidates, especially for patients under acceptable rhythm or rate control. 301