Catheter Ablation versus Standard conventional Treatment in patients with LEft ventricular dysfunction and Atrial Fibrillation - CASTLE-AF

Contribution To Literature:

The CASTLE-AF trial showed that catheter ablation was superior at preventing death or heart failure admissions.


The goal of the trial was to evaluate catheter ablation compared with standard treatment among patients with left ventricular dysfunction and atrial fibrillation.

Study Design

  • Randomized
  • Parallel

Patients with left ventricular dysfunction and atrial fibrillation were randomized to catheter ablation (n = 179) versus conventional treatment (n = 184).

  • Total number of enrollees: 363
  • Duration of follow-up: median 37.8 months
  • Mean patient age: 64 years
  • Mean left ventricular ejection fraction: 35%

Inclusion criteria:

  • Symptomatic paroxysmal or persistent atrial fibrillation
  • Intolerance or unwillingness to take at least one antiarrhythmic drug
  • Left ventricular ejection fraction: ≤35%
  • New York Heart Association class ≥2
  • Implantable cardioverter-defibrillator or cardiac resynchronization therapy-defibrillator with home monitoring capabilities

Principal Findings:

The primary outcome, incidence of death or hospitalization for heart failure, occurred in 28.5% of the catheter ablation group vs. 44.6% of the control group (p = 0.007).

  • All-cause mortality: 13.4% with catheter ablation vs. 25.0% with control (p = 0.01)
  • Hospitalization for heart failure: 20.7% with catheter ablation vs. 35.9% with control (p = 0.004)


Among patients with left ventricular dysfunction and atrial fibrillation, catheter ablation was superior to conventional treatment. Catheter ablation was associated with a reduction in deaths or hospitalizations for heart failure.


Marrouche NF, Brachmann J, Andresen D, et al., on behalf of the CASTLE-AF Investigators. Catheter Ablation for Atrial Fibrillation With Heart Failure. N Engl J Med 2018;Feb 1:[Epub ahead of print].

Editorial: Link MS. Paradigm Shift for Treatment of Atrial Fibrillation in Heart Failure. N Engl J Med 2018;Feb 1:[Epub ahead of print].

Presented by Dr. Nassir Marrouche at the European Society of Cardiology Congress, Barcelona, Spain, August 27, 2017.

Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Prevention, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure

Keywords: Arrhythmias, Cardiac, Atrial Fibrillation, Catheter Ablation, Cardiac Resynchronization Therapy Devices, Defibrillators, Implantable, ESC Congress, ESC2017, Heart Failure, Primary Prevention, Stroke Volume, Ventricular Dysfunction, Left

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