Catheter ablation has been shown to improve symptoms, exercise performance and neurohormonal status, as compared to medical (rate control) therapy in patients with co-existing atrial fibrillation (AF) and heart failure with reduced ejection fraction (HFrEF). Recent trials have suggested a reduction in early mortality associated with ablation in this group, however long-term outcomes remain unclear.

We performed a longitudinal follow-up of patients enrolled in the ARC-HF trial which randomised 52 patients (1:1) to undergo catheter ablation or medical therapy. All subjects had persistent AF, New York Heart Association class II-IV HF and a left ventricular ejection fraction ≤35% at enrolment. Follow-up was conducted through 31^st May 2018. The primary endpoint of this analysis was death from any cause.

After a median follow up of 7.2 years (IQR 5.1 to 8.0 years), 15 patients in the medical therapy arm had crossed over to ablation for refractory symptoms. The primary endpoint occurred in 16 patients overall (30.8%). Intention-to-treat analysis demonstrated that all-cause mortality did not significantly differ between patients randomised to ablation versus medical therapy (n=9 deaths [34.6%] ablation group vs. n=7 deaths [26.9%] control group, HR 1.36, 95% CI 0.51 to 3.66, p=0.54; see Figure). Improvement in peak VO₂, as was observed in the ARC-HF 12-month follow-up, was not significantly associated with long-term mortality.

While catheter ablation plays an important role in the management of refractory symptoms in patients with co-existing AF and HFrEF, it is not associated with a long-term reduction in all-cause mortality when compared with medical therapy. Appropriate patient selection is of paramount importance and future attempts to individualize therapy may identify a subgroup in which ablation provides a mortality benefit.