Pace and ablate better than drugs in patients with heart failure and atrial fibrillation: lessons from the APAF-CRT mortality trial

This editorial refers to ‘AV junction ablation and cardiac resynchronization for patients with permanent atrial fibrillation and narrow QRS: the APAF-CRT Mortality Trial’, by M. Brignole et al., doi:10.1093/eurheartj/ehab569. Many patients with heart failure (HF) develop atrial fibrillation (AF), and AF can cause HF often through high heart rates. Pulmonary vein catheter isolation (PVI) to cure AF is recommended to improve outcomes,1 but implementation has been slow. One reason may be that the recommendation is based on small studies of relatively young HF patients not resembling very much those we encounter in our everyday practice. In the CASTLE AF- trial,2 PVI ablation reduced total mortality and HF hospitalizations by an impressive 40% compared with pharmacological treatment. Study patients were in their early 60s with moderately symptomatic HF with reduced ejection fraction (HFrEF). It is important to remember that 3000 patients had to be screened to...