Table 4.2. Recommendations for atrial fibrillation ablation in HFrEF.
| Recommendations | Class | LE | Comments | Table 2018 |
Ref. |
|---|---|---|---|---|---|
| AF ablation to reestablish sinus rhythm in symptomatic patients, intolerant or refractory to antiarrhythmic medications to reduce mortality and hospitalizations for HF. | IIa | B | 2018 recommendation remains current. | Item 10.1 (page 465) |
See 2018 |
| AF ablation as an alternative to clinical treatment for selected patients with symptomatic persistent AF refractory or intolerant to at least one antiarrhythmic medication. | I | A | NEW: Randomized trials have shown a higher rate of success in sustaining a sinus rhythm with AF ablation, without antiarrhythmic medications side effects. | Item 10.1 (page 465) |
38–43 |
| AF ablation to promote reverse remodeling in patients with AF-induced tachycardiomyopathy if refractory to pharmacological treatment or if patient chooses ablation, regardless of symptoms. | I | B | NEW: A randomized trial showed AF ablation can promote reverse remodeling in patients with tachycardiomyopathy. | Item 10.1 (page 465) |
39–44 |
| In patients with HF, AF ablation is superior to medical treatment, as it is associated with improved maintenance of sinus rhythm, functional capacity and quality of life (6-minute walk test, VO2 max), in addition to greater reduction in biomarkers (BNP). It can be considered for selected patients with symptomatic persistent AF refractory or intolerant to at least one antiarrhythmic medication or even as initial therapy.38–43 Reverse remodeling was observed in several AF ablation trials, leading to increased LVEF.38–42,44 When the HF etiology is unknown and AF-induced tachycardiomyopathy is considered as a possible etiology, the expected increase in LVEF after ablation is even more significant.39,44 Studies demonstrated a reduction of 45% in hospitalizations for HF, 47/56% in all-cause mortality and 38% in mortality or hospitalization for HF.41,42,44 However, AF ablation success rates range from 60 to 80% in the first year and structural heart disease is a major risk factor for recurrence.45 Pulmonary vein isolation can be done by radiofrequency or cryoablation, and these techniques may be combined with the ablation of other substrates. | |||||
AF: atrial fibrillation; FC: functional class; HF: heart failure.