Catheter ablation shows efficacy in AF patients with end-stage HF

CASTLE-HTx: Catheter Ablation versus Medical Therapy to Treat Atrial Fibrillation in End-stage Heart Failure

News - Aug. 28, 2023

Presented at the ESC Congress 2023 by: Christian Sohns, MD - Bad Oeynhausen, Germany

Introduction and methods

Previously, the CASTLE-AF trial showed that catheter ablation reduced the risk of all-cause mortality or hospitalization for worsening HF compared with medical therapy alone in patients with AF and impaired LVEF. The question is whether AF ablation is also beneficial for patients with end-stage HF who are waiting for heart transplantation.

The CASTLE-HTx (Catheter Ablation for atrial fibrillation in patientS with end-sTage heart faiLure and Eligibility for Heart Transplantation) trial was a single-center, randomized, open-label, investigator-initiated study conducted at a German high-volume heart transplantation center. In this trial, 194 patients with symptomatic AF and end-stage HF who were eligible for heart transplantation were randomized to first-time catheter ablation or AF medical therapy (rate or rhythm control), in addition to guideline-directed HF therapy.

The primary endpoint was a composite outcome of all-cause mortality, worsening HF requiring urgent heart transplantation, or implantation of a left ventricular assist device (LVAD). Secondary endpoints included all-cause mortality.

The calculated follow-up time was ~3 years, but 1 year after randomization was completed, the Data Safety Monitoring Board terminated the study early for efficacy. Median follow-up duration was ~1.5 years.

Main results

  • The primary endpoint occurred in 8 patients (8.2%) in the ablation group and 29 (29.9%) in the medical-therapy group (HR: 0.24; 95%CI: 0.11–0.52; P<0.001).
  • The secondary endpoint all-cause mortality was observed in 6 patients (6.2%) in the ablation group and 19 (19.6%) in the medical-therapy group (HR: 0.09; 95%CI: 0.01–0.70; P<0.005).


In patients with end-stage HF, AF ablation was associated with a lower risk of all-cause mortality, urgent heart transplantation, or LVAD implantation compared with medical therapy. The researchers are convinced AF ablation should be considered a standard treatment option, besides drug therapyie, for this patient population, as it prolongs the life span of patients waiting for heart transplantation.

  • Our reporting is based on the information provided at the ESC Congress -

The results of this study were simultaneously published in N Engl J Med .

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