Research surrounding atrial fibrillation in heart failure

- So atrial fibrillation and heart failure are the two global pandemics in the cardiovascular arena. They both tend to worsen the outcomes of each other. And so there's been lots of interest in improving those outcomes over the last 20 years or so. Historically, the rhythm control strategy used to involve cardioverting these people and giving them anti-arrhythmic drugs, and the historical trials show no difference with that strategy and no improvement. More recently, with catheter ablation, the chances of maintaining sinus rhythm are much higher. And hence, there've been lots of head to head, randomised control trials, which have addressed this very issue.

Conflicts in this research

So it's very difficult to know in an individual patient what best to do because it's such a wide spectrum of patients. There are some people in whom atrial fibrillation is the fundamental reason for the heart failure or at least it's contributing to the heart failure. And it's those patients who you really want to address with ablation. Equally, there are some patients in whom atrial fibrillation happens as a byproduct of longstanding heart failure, almost as a end-stage disease. In them, there's little to gained by doing catheter ablation. So far, on the trials I have done have not made a distinction between these two subtypes. So essentially, all-comers with heart failure and atrial fibrillation have been included in these trials.

Further research required

The most important thing we need is to identify those patients with atrial fibrillation and heart failure who are likely to benefit from rhythm control with catheter ablation. So you are enriching that population and making the risks and the expense of catheter ablation worthwhile in these patients.

Considerations when approaching AF ablation

So, the most important thing to consider is that patients with congestive heart failure are very different from your usual AF ablation population. These patients are often sicker. They're often older, they have lots of co-morbidities. So the risk of complications is much higher. So you need to be aware that you're bringing your A game to the table when you're doing AF ablation in these people. So you need to do, you need to use your best technology. You need to be minimalistic in terms of what you can achieve because these patients often cannot tolerate long procedures and you need to be realistic in your expectations.

Take-home messages for clinicians

Well, first of all, be aware that now there are good quality data showing that rhythm control with catheter ablation improves outcomes in these patients. So often, these patients feel better. They have better objective criteria for performance, such as six-minute walk distance, levels of NT-proBNP levels. And often, they live longer as well. If you follow up these patients long enough. So the awareness is key and that education needs to be disseminated all through the, to the primary providers and secondary providers.