Catheter ablation in end-stage heart failure with atrial fibrillation: an hierarchical endpoint analysis of the CASTLE-HTx trial.
Maximilian Moersdorf, Johan Verbeeck, Nassir F Marrouche et al.
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In 30 seconds
This ancillary hierarchical endpoint analysis of the multicentre randomized CASTLE-HTx trial compared catheter ablation plus guideline-directed medical therapy (GDMT) with medical therapy alone in 194 patients with end-stage heart failure and atrial fibrillation. Using generalized pairwise comparisons of death, urgent heart transplantation, left-ventricular assist device implantation, and worsening-heart-failure hospitalizations, 61.6% of patient pairs favoured ablation, 26.4% favoured medical therapy, and 12.0% were tied. At 3 years, the restricted net treatment benefit was 35.3% (95% CI, 19.8-49.0; P < .001), favouring ablation.
Key findings
- At 3 years, the restricted net treatment benefit for the hierarchical outcome was 35.3% (95% CI, 19.8-49.0; P < .001), with win odds of 2.09 (95% CI, 1.49-2.92).
- Pairs favoured ablation over medical therapy for death from any cause (28.4%/12.4%) and worsening-heart-failure hospitalizations (24.8%/11.3%).
- In the secondary analysis, the restricted net treatment benefit was 38.4% (95% CI, 22.8-52.0; P < .001), with win odds of 2.25 (95% CI, 1.59-3.17).
Why it matters
The analysis places mortality, urgent transplantation, LVAD implantation, and heart-failure hospitalizations in a clinical hierarchy, offering a broader view of outcomes than a single composite alone. Its results suggest that the overall advantage associated with ablation in this trial was driven mainly by mortality and heart-failure hospitalizations, outcomes central to the course of end-stage heart failure.
What to keep in mind
This is an ancillary analysis of one trial, and the hierarchical pairwise method and endpoint ordering shape the reported treatment benefit.