Time to Storm the Next CASTLE: Can Atrial Fibrillation Ablation Improve Outcomes in Patients With Heart Failure and Preserved Ejection Fraction?

Abstract Purpose of Review Heart failure with preserved ejection fraction and atrial fibrillation frequently coexist and are linked by shared mechanisms including atrial myopathy, elevated filling pressures, fibrosis, and adverse hemodynamic interactions. The combination of both diseases worsens patient outcomes, and catheter ablation has emerged as a potentially important treatment strategy in this population. This review aims to summarize and highlight the current evidence on ablation in patients with atrial fibrillation and HFpEF. Recent Findings When examining outcomes of mortality, hospitalization, hemodynamics, and recurrence, ablation appears to be superior to medical treatment with some mixed results. However, no large trials have been conducted on the topic, and no clear guidelines for ablation in HFpEF patients exist. Summary Ablation is promising but not yet definitive for patients with atrial fibrillation and HFpEF. Ongoing trials, including CASTLE-HFpEF should clarify the gaps including patient selection, procedural strategy, and outcome benefit.