Atrial Fibrillation Ablation in Heart Failure

Sergio Richter; Luigi Di Biase; Gerhard Hindricks

Disclosures

Eur Heart J. 2019;40(8):663-671. 

In This Article

Abstract and Introduction

Abstract

This review summarizes the rationale and current scientific evidence for catheter ablation in patients with atrial fibrillation and concomitant heart failure, puts it in context with recent practice recommendations, and discusses emerging technologies and future directions.

Introduction

" A journey of a thousand miles begins with a single step."
Laozi (Chinese philosopher 604–531 BC)

Atrial fibrillation (AF) is the most common cardiac arrhythmia with an estimated worldwide prevalence of 1.5–2.0% in the general population. The incidence of AF is further predicted to increase twofold over the next decades owing mainly to a steadily aging population with growing burden of cardiovascular comorbidities.[1,2] The lifetime risk of AF is one in four individuals aged >55 years.[3] This epidemiological course needs strongly to be considered in the light of the fact that AF carries risk of significant morbidity and mortality.[4] Of particular importance, AF is associated with the development and deterioration of left ventricular (LV) dysfunction and systolic and diastolic heart failure (HF).[5,6] Conversely, LV dysfunction promotes atrial structural and electrical changes that facilitate the occurrence and maintenance of AF.[7] Therefore, the concept of AF begets HF and HF begets AF has been well appreciated.[8] Both conditions share common pathophysiological mechanisms and underlying risk factors and independently predict each other.[9,10] The prevalence of AF among patients with HF is in the range of 10–57% depending on age, onset and severity of HF,[7,8] whereas the rate of HF ranges between 40% and 55% in patients with persistent and long-standing persistent AF.[11] Not surprisingly, the related twin epidemics of cardiovascular disease with increased risk of mortality synergistically confer worse outcomes compared with either condition alone.[10,12] Given the poor prognosis associated with concomitant AF and HF, it is of paramount importance to elaborate effective and safe treatment strategies to prevent or reverse the occurrence of AF in patients with HF and reduced ejection fraction (HFrEF). Since most of the conventional antiarrhythmic drugs (AADs) are contraindicated, frequently ineffective, or not well-tolerated in patients with HFrEF, catheter ablation of AF provides an increasingly important option for AAD-free rhythm control in these patients.

Therefore, this review summarizes the rationale and current scientific evidence for catheter ablation in patients with AF and HFrEF, puts it in context with recent practice recommendations, and discusses emerging technologies and future directions.

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