What is the role of catheter ablation in patients with atrial fibrillation and HFpEF?

Dr Jonathan Piccini discusses rhythm control in patients with atrial fibrillation and heart failure with preserved ejection fraction, the growing role of catheter ablation, and the evidence still needed to define its impact on cardiovascular outcomes.

Atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF) frequently coexist, creating a challenging clinical picture in which symptom burden, stroke risk, exercise intolerance and multiple comorbidities all need to be considered. Alongside optimization of heart failure therapy and stroke prevention, rhythm control is an important part of management for many patients.

At ESC Congress 2026, Dr Jonathan Piccini, Duke University Hospital and the Duke Clinical Research Institute, discussed the role of catheter ablation in patients with AF and HFpEF. He spoke with touchCARDIO about current treatment, why ablation is increasingly being used, how he approaches treatment decisions in practice, and the potential impact on symptoms and quality of life.

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What does standard therapy currently look like for patients with AF and HFpEF, and where are the remaining unmet needs?

Patients with atrial fibrillation who also have heart failure with preserved ejection fraction require the same core considerations as any patient with AF, but there are some areas that deserve particular attention.

First, we need to pay very close attention to their risk factors. We also need to assess the need for stroke prevention therapy, and almost all of these patients will have an indication for stroke prevention.

Beyond that, we want to help patients feel better. That means paying attention to rhythm control where appropriate, either with antiarrhythmic drug therapy or with catheter ablation. So the management strategy really needs to address stroke prevention, the underlying heart failure and the burden of atrial fibrillation itself.

The role of catheter ablation appears to be growing. Why is that, and what do we know about outcomes?

If we put HFpEF aside for a moment and look more broadly at atrial fibrillation, the most recent guidelines and the trials supporting them show that we now have a substantial body of evidence demonstrating that first-line catheter ablation produces better outcomes than first-line antiarrhythmic drug therapy. That is one major reason why we are seeing greater use of ablation.

Another important area is heart failure with reduced ejection fraction. Here, we have seen in not just one but multiple clinical trials that catheter ablation can improve outcomes compared with medical therapy alone.

HFpEF is a little different because we do not yet have the same large randomized clinical trial evidence. There are, however, several studies that are either planned or ongoing, including trials such as CABA-HFpEF and CABANA-HF, which should hopefully help answer the important question of whether catheter ablation improves cardiovascular outcomes in patients with atrial fibrillation and HFpEF.

So there is already strong evidence supporting ablation in other AF populations, and the next step is to establish more clearly whether those benefits extend to cardiovascular outcomes in HFpEF.

How do you decide between antiarrhythmic drug therapy and catheter ablation in your own clinical practice?

In our clinic, when we see a patient who has atrial fibrillation together with HFpEF, the first thing we want to do is make sure that they are receiving comprehensive care for their heart failure.

We want them to be seen in our HFpEF clinic and to ensure they are receiving the best available medical therapy, including appropriate diuretic therapy and SGLT2 inhibitor therapy. From a rhythm-control perspective, we offer patients either antiarrhythmic drugs or catheter ablation. However, many of our patients have multiple comorbidities that make antiarrhythmic drug treatment challenging. Because of that, in our center, catheter ablation becomes the preferred method of rhythm control for a very large proportion of these patients.

It is therefore not simply a question of choosing one strategy in isolation. We need to optimize the HFpEF treatment, assess the individual patient’s comorbidities, look at the feasibility of antiarrhythmic drug therapy and then decide which rhythm-control strategy is most appropriate.

Is there also a quality-of-life benefit associated with catheter ablation in these patients?

Absolutely. In data from our Duke Center for Atrial Fibrillation, we found that after catheter ablation, a very large percentage of patients with HFpEF no longer had symptoms of heart failure, or they had improved to New York Heart Association [NYHA] class I. They also experienced less frequent symptoms from their atrial fibrillation. Importantly, their exercise tolerance improved significantly as well. So yes, I think there is a very strong quality-of-life indication for catheter ablation in this population.

Even while we are waiting for larger randomized trials to determine whether ablation improves major cardiovascular outcomes in HFpEF, the potential to reduce AF symptoms, improve functional status and increase exercise tolerance is highly relevant to patients.

 Looking across ESC Congress 2026, what new evidence are you particularly interested in seeing?

That is a difficult question because there is so much incredible science and so much data being shared at this meeting. Personally, I am most interested in seeing the results of the sham PVI trial.

I do not know what the results are, so we will have to see what they show, but I hope the findings will be useful in addressing some of the remaining skepticism about whether catheter ablation can truly be helpful for patients. There is already a substantial evidence base supporting catheter ablation, but studies like this can help us continue to understand the magnitude and nature of the benefit and, hopefully, give us greater confidence about which patients should be offered the procedure.