Key Findings.
-
▪
A personalized, dispersion-guided ablation targeting regions of spatiotemporal dispersion improves the freedom from atrial fibrillation after a single procedure when compared with anatomical pulmonary vein isolation across all New York Heart Association (NYHA) classes.
-
▪
A tailored ablation strategy is beneficial in terms of freedom from any arrhythmia in patients with advanced heart failure (NYHA class III).
-
▪
These findings highlight the importance of implementing individualized ablation strategies in patients with heart failure.
Atrial fibrillation (AF) and heart failure (HF) frequently coexist, creating a complex clinical scenario that amplifies morbidity and worsens prognosis. Catheter ablation emerged as a cornerstone therapy for rhythm control in this population, particularly in patients with reduced ejection fraction.1 However, the optimal ablation strategy remains debated, especially in those with advanced HF symptoms. This research letter presents a sub-analysis of the Tailored vs Anatomical Ablation Strategy for Persistent Atrial Fibrillation (TAILORED-AF) trial, which investigated the efficacy of a personalized, dispersion-guided ablation strategy targeting regions of spatiotemporal dispersion (tailored arm) compared with conventional anatomical pulmonary vein isolation (PVI, anatomical arm) in patients with persistent AF.2 Here, we focus on outcomes stratified by New York Heart Association (NYHA) functional class to assess whether the benefits of the tailored approach vary with HF severity.
This sub-analysis included 279 patients: 69 NYHA I (32 tailored, 37 anatomical), 160 NYHA II (85 tailored, 75 anatomical), and 50 NYHA III (26 tailored, 24 anatomical). The personalized strategy incorporated high-density mapping to identify dispersion zones, which were then targeted for ablation in addition to PVI. The end points were freedom from AF (FFAF) and freedom from atrial arrhythmia (FFAF/AT) at 12 months following 1 or 2 procedures. There was no difference in procedure time in the tailored arm across the NYHA classes (NYHA I: 180 ± 53 min; NYHA II: 177 ± 65 min; NYHA III: 190 ± 46 min; P = .55). A similar finding was observed in the anatomical arm (P = .84). FFAF after a single procedure was higher in the tailored arm than in the anatomical arm across NYHA classes: NYHA I (88% vs 62%, P < .05), NYHA II (87% vs 68%, P < .01), and NYHA III (92% vs 71%, P = .07). In terms of FFAF/AT after a single procedure or 1 or 2 procedures, no differences were observed between the arms for NYHA classes I and II (P > .05, Figure 1). However, for NYHA class III patients, a numerical difference was observed in favor of the tailored arm after a single procedure (77% vs 54%, P = .14), reaching significance after 1 or 2 procedures (96% vs 62%, P < .01).
Figure 1.
Personalized ablation strategy versus pulmonary vein isolation for persistent atrial fibrillation patients across New York Heart Association (NYHA) classes. Percentage of freedom from atrial fibrillation (AF) after a single procedure (A), freedom from AF and/or atrial tachycardias (AT) after a single procedure (B) and freedom from AF/AT after 1 or 2 procedures (C) in the tailored and anatomical arm. Patients stratified by NYHA class. NYHA I: no limitation of physical activity; NYHA II: slight limitation of physical activity; NYHA III: marked limitation of physical activity. Data compared using the Fisher’s exact test. ∗P < .05; ∗∗P < .01.
These findings suggest that the personalized, dispersion-guided ablation strategy may be particularly beneficial in patients with more advanced HF symptoms. As HF progresses, atrial remodeling becomes more extensive, with increased fibrosis and conduction heterogeneity. In such cases, anatomical PVI alone may be insufficient to address the arrhythmogenic substrate.3 By identifying and targeting regions of spatiotemporal dispersion, the tailored approach offers a more comprehensive modification of the electrophysiological environment responsible for AF maintenance.4 Importantly, the personalized strategy did not result in increased procedural complications (1 patient NYHA I, 2 NYHA II, and none NYHA III experienced major procedure-related complications in the tailored arm, P > .99), indicating that the integration of dispersion mapping into ablation workflows is feasible and safe.
The relevance of personalized, dispersion-guided ablation is further supported by recent data from the Catheter Ablation for Atrial Fibrillation in Patients With End-Stage Heart Failure and Eligibility for Heart Transplantation (CASTLE-HTx) trial, which demonstrated that catheter ablation significantly reduced mortality and the need for advanced HF therapies in patients with end-stage HF and AF.5 While CASTLE-HTx focused on a different population, it reinforces the concept that rhythm control via ablation can yield substantial clinical benefits in patients with HF, particularly when a tailored approach is followed to adjust ablation to the underlying electrophysiological complexity.
In conclusion, this sub-analysis of the TAILORED-AF trial demonstrates that personalized, dispersion-guided ablation targeting regions of spatiotemporal dispersion improves FFAF compared with anatomical PVI across NYHA classes. Patients with NYHA class III symptoms derived a significant benefit from tailored ablation compared with PVI in terms of FFAF/AT after 1 or 2 procedures. These findings emphasize the importance of individualized ablation strategies and provide a rationale for further prospective studies in HF populations.
Disclosures
The authors have no conflicts of interest to disclose.
Acknowledgments
Registration Identification
Funding Sources
This study is funded by Volta Medical.
Authorship
All authors attest they meet the current ICMJE criteria for authorship.
Patient Consent
All patients provided written informed consent.
Ethics Statement
The trial received Investigational Device Exemption by the Food and Drug Administration (since the use of the AI adjudication system to guide ablation is investigational in the United States) and was approved by the institutional or ethics review board at each center: Western IRB (WIRB), Ascension St. Vincent IRB, Rhode Island Hospital IRB (United States), CPP SUD-EST IV (France), Technische Universitat Munchen (TUM) Ethikkommission, Landesarztekammer Baden-Wurttemberg Ethikkommission (Germany), OLV Ziekenhuis vzw Ethisch Comite (Belgium), and Brabant Medical Ethics Committee (Netherlands). The study was conducted in accordance with principles of the Declaration of Helsinki.
Disclaimer
Given her role as Associate Editor, Isabel Deisenhofer had no involvement in the peer review of this article and has no access to information regarding its peer review. Full responsibility for the editorial process for this article was delegated to Editor-in-Chief Jeanne E. Poole and Deputy Editor Hamid Ghanbari.
References
- 1.Zeitler E.P., Johnson A.E., Cooper L.B., Steinberg B.A., Houston B.A. Atrial fibrillation and heart failure with reduced ejection fraction: new assessment of an old problem. JACC Heart Fail. 2024;12:1528–1539. doi: 10.1016/j.jchf.2024.06.016. [DOI] [PubMed] [Google Scholar]
- 2.Deisenhofer I., Albenque J.P., Busch S., et al. Artificial intelligence for individualized treatment of persistent atrial fibrillation: a randomized controlled trial. Nat Med. 2025;31:1286–1293. doi: 10.1038/s41591-025-03517-w. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Marascu G.E., Deaconu A.I., Mitran R.E., Stanciulescu L.A., Vatasescu R.G. Targeting the substrate: mechanism-based ablation strategies for persistent AF. J Clin Med. 2025;14:5147. doi: 10.3390/jcm14145147. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Pajareya P., Kaewkanha P., Singtong B., et al. Efficacy and safety of spatiotemporal electrogram dispersion ablation with PVI in persistent AF: a meta-analysis. J Cardiovasc Electrophysiol. 2025;36:2485–2497. doi: 10.1111/jce.70036. [DOI] [PubMed] [Google Scholar]
- 5.Sohns C., Fox H., Marrouche N.F., et al. Catheter ablation in end-stage heart failure with atrial fibrillation. N Engl J Med. 2023;389:1380–1389. doi: 10.1056/NEJMoa2306037. [DOI] [PubMed] [Google Scholar]