PRO/CON Debate: Atrial Fibrillation Ablation in Older Adults With Heart Failure and Reduced Ejection Fraction: Please Ablate

Quick Takes

  • Heart failure (HF) and atrial fibrillation (AF) are a bad combination, such that AF can exacerbate HF symptoms, worsen left ventricular function, and create multiple adverse consequences despite optimal medical therapy for HF.
  • Maintenance of sinus rhythm in patients with HF and AF can improve outcomes, but antiarrhythmic drug therapy is inferior to catheter ablation in this regard.
  • Evidence indicates that age, per se, is not a contraindication to catheter ablation of AF, even for patients with HF with reduced ejection fraction (EF) or HF with preserved EF, and catheter ablation can be performed safely and effectively even in those >80 years of age.

The PRO portion of the currently featured PRO/CON debate between Dr. Brian Olshansky and Dr. John Mandrola presents a significant conundrum within the fields of electrophysiology and geriatric cardiology.

It is widely recognized that cardiovascular (CV) clinical trials often fail to enroll an adequate number of older adults. Furthermore, in the rare instances when they focus on recruiting older participants, there is a lack of representation of real-life older adults. These real-life individuals are thought to typically exhibit a higher magnitude of complex underlying physical, cognitive, financial, and social conditions. Moreover, their underlying values, preferences, and priorities are often not well understood.

This debate represents a stride toward creating a more effective approach to geriatric CV care within the electrophysiological sphere. It involves the determination of not only CV factors but also intricate geriatric conditions and considers what matters most to the patient. The hope is that readers enjoy the current collection of pieces exploring this debate.

See the brief clinical vignette in this pollMr. PT is an 82-year-old man who presents with persistent, mildly symptomatic atrial fibrillation (AF) of approximately 4-5 months' duration. He also has heart failure with reduced ejection fraction (HFrEF), New York Heart Association (NYHA) class II heart failure (HF) symptoms and left ventricular ejection fraction (LVEF) 40%.

  • AF and HF are a bad combination, with AF contributing to worsening HF by multiple mechanisms, including irregular rate, loss of atrial "kick," tachycardia, and inappropriate rate response.1
  • Outcomes of patients with HF and AF are not improved with a rhythm-control drug strategy versus a rate-control approach; antiarrhythmic drugs to suppress AF are often ineffective and cause serious adverse effects.
  • Ablation is more effective to prevent AF than is medical therapy based on the results of randomized, prospective, controlled trials of patients with HF, including the AATAC (Ablation vs. Amiodarone for Treatment of Atrial Fibrillation in Patients With Congestive Heart Failure and Implanted ICD/CRTD) trial of patients with HFrEF, the RAFT-AF (A Randomized Ablation-based atrial Fibrillation rhythm control versus rate control Trial in patients with heart failure and high burden Atrial Fibrillation)2 of patients with HFrEF and HF with preserved ejection fraction, and others. AF ablation in patients with HF is associated with better LVEF, 6-min walk test distance, N-terminal pro–B-type natriuretic peptide levels, and quality of life.
  • The results of randomized prospective trials, including the CASTLE-AF (Catheter Ablation versus Standard conventional Treatment in patients with LEft ventricular dysfunction and Atrial Fibrillation )3 trial of patients with HFrEF and the CASTLE HTx (Catheter Ablation in End-Stage Heart Failure With Atrial Fibrillation)4 trial of patients with "end-stage HF," showed highly significant benefit of ablation versus medical therapy on the basis of multiple endpoints, including survival. These data, supported by the results of a post hoc analysis from the CABANA (Catheter ABlation vs ANtiarrhythmic Drug Therapy in Atrial Fibrillation) trial, may benefit patients by reversal of arrhythmia-induced cardiomyopathy,1 or by other mechanisms.
  • AF ablation success rates are similar in adults >75 years of age and in younger adults based on the results of multiple studies.5 Data from Japan indicate that patients with AF >80 years of age have similar success and complication rates to those <80 years of age regarding CV events, AF recurrence, CV deaths, and permanent AF6,7; similar data exist in US databases.8 According to ablation data from these older populations, 28-42% of patients had HF.
  • AF ablation can improve symptom severity, anxiety, and depression.9 Early ablation after presentation with HF and AF appears associated with improved survival rates compared with rates in a matched cohort attempting a strategy of initial medical therapy.10
  • Although ablation data in older adults have limitations including selection bias, investigator bias, lack of sham control and, in some instances, only being observational data, all available data to date indicate that AF ablation in older adults is the most effective and safest way to improve outcomes of older adults with AF and HF (Figure 1).

Figure 1

Figure 1: Atrial Fibrillation and Heart Failure in Older Patients
Figure 1: Atrial Fibrillation and Heart Failure in Older Patients. Courtesy of Olshansky O.


  1. Gopinathannair R, Chen LY, Chung MK, et al.; American Heart Association Electrocardiography and Arrhythmias Committee and Heart Failure and Transplantation Committee of the Council on Clinical Cardiology, Council on Arteriosclerosis, Thrombosis and Vascular Biology, Council on Hypertension, Council on Lifestyle and Cardiometabolic Health, the Stroke Council. Managing atrial fibrillation in patients with heart failure and reduced ejection fraction: a scientific statement from the American Heart Association. Circ Arrhythm Electrophysiol 2021;14: HAE0000000000000078.
  2. Parkash R, Wells GA, Rouleau J, et al. Randomized ablation-based rhythm-control versus rate-control trial in patients with heart failure and atrial fibrillation: results from the RAFT-AF trial. Circulation 2022;145:1693-704.
  3. Marrouche NF, Brachmann J, Andresen D, et al.; CASTLE-AF Investigators. Catheter ablation for atrial fibrillation with heart failure. N Engl J Med 2018;378:417-27.
  4. Sohns C, Fox H, Marrouche NF, et al.; CASTLE HTx Investigators. Catheter ablation in end-stage heart failure with atrial fibrillation. N Engl J Med 2023;389:1380-9.
  5. Prasitlumkum N, Tokavanich N, Trongtorsak A, et al. Catheter ablation for atrial fibrillation in the elderly >75 years old: systematic review and meta-analysis. J Cardiovasc Electrophysiol 2022;33:1435-49.
  6. Okamatsu H, Okumura K, Onishi F, et al. Safety and efficacy of ablation index-guided atrial fibrillation ablation in octogenarians. Clin Cardiol 2023;46:794-800.
  7. Okawa K, Taya S, Morimoto T, et al. Cardiovascular events and death after catheter ablation in very old patients with nonvalvular atrial fibrillation. Aging (Albany NY) 2023;15:7343-61.
  8. Aldaas OM, Darden D, Mylavarapu PS, et al. Safety and efficacy of catheter ablation of atrial fibrillation in the very elderly (≥80 years old): insights from the UC San Diego AF Ablation Registry. Clin Cardiol 2023;46:1488-94.
  9. Al-Kaisey AM, Parameswaran R, Bryant C, et al. Atrial fibrillation catheter ablation vs medical therapy and psychological distress: a randomized clinical trial. JAMA 2023;330:925-33.
  10. Sakamoto K, Tohyama T, Ide T, et al. Efficacy of early catheter ablation for atrial fibrillation after admission for heart failure. JACC Clin Electrophysiol 2023;9:1948-59.

Clinical Topics: Arrhythmias and Clinical EP, Geriatric Cardiology, Atrial Fibrillation/Supraventricular Arrhythmias, Heart Failure and Cardiomyopathies, Anticoagulation Management

Keywords: Ablation, Geriatrics, Atrial Fibrillation, Aged

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