Who Benefits Most? Patient Selection for Atrial Fibrillation Catheter Ablation in Heart Failure

AF and heart failure (HF) often coexist, amplifying morbidity and mortality. Catheter ablation is an effective rhythm control strategy, particularly in heart failure with reduced ejection fraction, where studies such as CASTLE-AF show improved survival, fewer HF hospitalisations and better quality of life. Evidence in HF with preserved ejection fraction is emerging; RAFT-AF included HF with preserved ejection fraction patients, but showed no significant primary outcome difference, though subgroup data offer insights across the HF spectrum. Procedural risks, influenced by patient frailty and device presence (e.g. left ventricular assist devices and CRT), necessitate careful selection and periprocedural optimisation. Advances in ablation technology, including pulsed field ablation, and adjunctive strategies show promise but require further validation. Early rhythm control, as supported by EAST-AFNET 4, may prevent adverse remodelling and improve outcomes if applied before extensive atrial disease develops. Future directions emphasise multidisciplinary, personalised approaches integrating imaging and biomarkers to optimise patient selection. Thoughtful application of catheter ablation can enhance outcomes in carefully selected HF patients with AF.