Key result
Catheter ablation plus GDMT improved the hierarchical composite of mortality, urgent transplantation, LVAD implantation, and HF hospitalizations versus medical therapy alone (win odds 2.09; P<0.001).
Why the study?
To perform an ancillary analysis of the CASTLE-HTx trial using generalized pairwise comparison methodology on main outcomes in patients with end-stage HF and AF.
Does catheter ablation added to GDMT improve a hierarchical composite of mortality, urgent HTx, LVAD implantation, and HF hospitalizations in patients with end-stage HF and AF?
RCT (n=194)
randomized
Does catheter ablation added to GDMT improve a hierarchical composite of mortality, urgent HTx, LVAD implantation, and HF hospitalizations in patients with end-stage HF and AF?
In patients with end-stage heart failure and atrial fibrillation, catheter ablation added to GDMT significantly improved a hierarchical composite of mortality, urgent heart transplantation, LVAD implantation, and heart failure hospitalizations compared to GDMT alone.
Answers are grounded in this paper and cite their sources.
Supports ablation plus GDMT in end-stage HF with AF; extends CASTLE-HTx with quantified 3-year net benefit.
Background The CASTLE-HTx trial (NCT04649801) showed that the combination of catheter ablation and guideline-directed medical therapy (GDMT) was associated with a lower likelihood of a composite of death from any cause, implantation of a left-ventricular assist device (LVAD), or heart transplantation (HTx) in patients with end-stage heart failure (HF) and atrial fibrillation (AF). Aims This is an ancillary analysis with the generalized pairwise comparison methodology of the main outcomes of CASTLE-HTx. Methods In CASTLE-HTX, 194 patients were randomized to catheter ablation and GDMT (n = 97) or medical therapy alone (n = 97). The first hierarchical outcome was a composite of (1) death from any cause, (2) urgent HTx, (3) implantation of an LVAD, and (4) frequency of hospitalizations for worsening HF. Secondary analysis also included AF burden and left-ventricular ejection fraction improvement. Treatment effects are reported as net treatment benefit (NTB) and win odds, with corresponding confidence intervals (CIs). Results Patients randomized to ablation had more wins with respect to death from any cause (28.4%/12.4%), HTx (4.3%/2.1%), LVAD implantation (4.2%/0.6%), and hospitalizations for worsening HF (24.8%/11.3%). 61.6% of pairs favoured ablation, 26.4% medical therapy, and 12.0% were tied. This resulted in a restricted NTB at 3 years of 35.3% (95% CI, 19.8−49.0, P < .001) favouring ablation (win odds: 2.09; 95% CI, 1.49−2.92). In the secondary analysis, 67.0% of pairs favoured ablation against 28.6% of pairs favouring medical therapy. The restricted NTB was 38.4% (95% CI, 22.8−52.0, P < .001) in favour of ablation (win odds: 2.25; 95% CI, 1.59−3.17). Conclusions This pairwise analysis of CASTLE-HTx confirms the clinical benefits of early catheter ablation in addition to GDMT among AF patients in end-stage HF. The treatment benefit was primarily driven by mortality and HF hospitalizations.
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Moersdorf et al. (2026) conducted an RCT in End-stage heart failure and atrial fibrillation (n=194). Catheter ablation and guideline-directed medical therapy vs. Medical therapy alone was evaluated on Hierarchical composite of death from any cause, urgent HTx, LVAD implantation, and frequency of hospitalizations for worsening HF (win odds 2.09, 95% CI 1.49-2.92, p=<.001). Catheter ablation plus GDMT improved the hierarchical composite of mortality, urgent transplantation, LVAD implantation, and HF hospitalizations versus medical therapy alone (win odds 2.09; P<0.001).
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