Cost-effectiveness of catheter ablation in end-stage heart failure with atrial fibrillation: Insights from CASTLE-HTx

BACKGROUND: The CASTLE-HTx (Catheter Ablation for Atrial Fibrillation in patientS With End-sTage Heart Failure and Eligibility for Heart Transplantation; ClinicalTrials.gov identifier NCT04649801) trial 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, or heart transplantation (HTx) in patients with end-stage heart failure (HF) and atrial fibrillation (AF). OBJECTIVE: This analysis evaluates the cost-effectiveness of catheter ablation plus GDMT vs medical therapy alone in patients with end-stage HF and AF referred for HTx evaluation. METHODS: In CASTLE-HTx, we randomized 194 patients in end-stage HF and AF to receive catheter ablation and GDMT (n = 97) or medical therapy alone (n = 97). Details of study design, outcome definitions, and results have been published. A cohort-based Markov model projected lifetime costs, life-years (LYs), and quality-adjusted life-years (QALYs) from the perspective of the German statutory health insurance system using 3-year outcomes from CASTLE-HTx. RESULTS: In lifetime projections, the combination of AF ablation and GDMT was associated with a mean survival gain of ∼1.7 LYs per patient at an incremental cost of ∼€12,000, yielding an incremental cost-effectiveness ratio of ∼€7300 per LY gained. The incremental cost-effectiveness ratios per QALY in lifetime projections (€8600) and at 36 months (€30,400) were below €50,000 per QALY, indicating cost-effectiveness at contemporary thresholds. Within 36 months, this survival benefit resulted in a gain of 0.34 LYs, reflecting prevention of death and worsening HF. The long-term benefit emerged early and remained consistent across sensitivity analyses. CONCLUSION: The combination of catheter ablation and GDMT is cost-effective and economically favorable in patients with end-stage HF and AF who are referred for HTx evaluation.