对于许多心力衰竭（HF）和心房颤动（AF）患者，我们更倾向于AF管理的速率控制策略。用药物治疗（例如抗心律失常药物）或导管消融（CA）可以实现节律控制。在许多这些患者中支持使用CA的最有力证据来自CASTLE-AF随机试验，该试验将363名有症状阵发性或持续性房颤患者的CA与药物治疗（心率或心律控制）进行比较;纽约心脏协会II，III或IV类HF;左心室射血分数≤35％;失败或不愿意服用抗心律失常药物治疗;和植入式心脏复律除颤器。 CA显着降低了因任何原因造成的主要复合终点或因HF恶化而住院治疗。根据CASTLE-AF的结果，我们现在建议将CA作为适用于所选择的AF和HF患者的适当治疗，因为他们最初尝试抗心律失常疗法是无效的。
BACKGROUND Mortality and morbidity are higher among patients with atrial fibrillation and heart failure than among those with heart failure alone. Catheter ablation for atrial fibrillation has been proposed as a means of improving outcomes among patients with heart failure who are otherwise receiving appropriate treatment.
METHODS We randomly assigned patients with symptomatic paroxysmal or persistent atrial fibrillation who did not have a response toantiarrhythmic drugs, had unacceptable side effects, or were unwilling to take these drugs to undergo either catheter ablation (179 patients) or medical therapy (rate or rhythm control) (184 patients) for atrial fibrillation in addition to guidelines-based therapy for heart failure. All the patients had New York Heart Association class II, III, or IV heart failure, a left ventricular ejection fraction of 35% or less, and an implanted defibrillator. The primary end point was a composite of death from any cause or hospitalization for worsening heart failure.
RESULTS After a median follow-up of 37.8 months, the primary composite end point occurred in significantly fewer patients in the ablation group than in the medical-therapy group (51 patients [28.5%]vs. 82 patients [44.6%]; hazard ratio, 0.62; 95% confidence interval [CI], 0.43 to 0.87; P=0.007). Significantly fewer patients in the ablation group died from any cause (24 [13.4%]vs. 46 [25.0%]; hazard ratio, 0.53; 95% CI, 0.32 to 0.86; P=0.01), were hospitalized for worsening heart failure (37 [20.7%]vs. 66 [35.9%]; hazard ratio, 0.56; 95% CI, 0.37 to 0.83; P=0.004), or died from cardiovascular causes (20 [11.2%]vs. 41 [22.3%]; hazard ratio, 0.49; 95% CI, 0.29 to 0.84; P=0.009).
CONCLUSIONS Catheter ablation for atrial fibrillation in patients with heart failure was associated with a significantly lower rate of a composite end point of death from any cause or hospitalization for worsening heart failure than was medical therapy. (Funded by Biotronik; CASTLE-AF ClinicalTrials.gov number, NCT00643188 .).
