Cost-effectiveness of catheter ablation in end-stage heart failure with atrial fibrillation: insights from CASTLE-HTx

Priyanka Boettger, Maximilian Moersdorf, Philipp Sommer, Nassir F. Marrouche, Angelika Costard-Jaeckle, Harry J.G.M. Crijns, Leonard Bergau, Henrik Fox, Gerhard Hindricks, Nikolaos Dagres, Rene Schramm, Thomas Fink, Moneeb Khalaph, Vanessa Sciacca, Maxim Didenko, Frank Konietschke, Volker Rudolph, Jan Gummert, Jan G.P. Tijssen, Samuel Sossalla and Christian Sohns

LSE Research Online Documents on Economics from London School of Economics and Political Science, LSE Library

Abstract: Background The CASTLE-HTx (Catheter Ablation for Atrial Fibrillation in patientS With End-sTage Heart Failure and Eligibility for Heart Transplantation; ClinicalTrials.gov identifier NCT04649801) trial showed that the combination of catheter ablation and guideline-directed medical therapy (GDMT) was associated with a lower likelihood of a composite of death from any cause, implantation of a left ventricular assist device, or heart transplantation (HTx) in patients with end-stage heart failure (HF) and atrial fibrillation (AF). Objective This analysis evaluates the cost-effectiveness of catheter ablation plus GDMT vs medical therapy alone in patients with end-stage HF and AF referred for HTx evaluation. Methods In CASTLE-HTx, we randomized 194 patients in end-stage HF and AF to receive catheter ablation and GDMT (n = 97) or medical therapy alone (n = 97). Details of study design, outcome definitions, and results have been published. A cohort-based Markov model projected lifetime costs, life-years (LYs), and quality-adjusted life-years (QALYs) from the perspective of the German statutory health insurance system using 3-year outcomes from CASTLE-HTx. Results In lifetime projections, the combination of AF ablation and GDMT was associated with a mean survival gain of ∼1.7 LYs per patient at an incremental cost of ∼€12,000, yielding an incremental cost-effectiveness ratio of ∼€7300 per LY gained. The incremental cost-effectiveness ratios per QALY in lifetime projections (€8600) and at 36 months (€30,400) were below €50,000 per QALY, indicating cost-effectiveness at contemporary thresholds. Within 36 months, this survival benefit resulted in a gain of 0.34 LYs, reflecting prevention of death and worsening HF. The long-term benefit emerged early and remained consistent across sensitivity analyses. Conclusion The combination of catheter ablation and GDMT is cost-effective and economically favorable in patients with end-stage HF and AF who are referred for HTx evaluation.

Keywords: heart failure; atrial fibrillation; heart transplantation; catheter ablation; cost-effectiveness (search for similar items in EconPapers)
JEL-codes: J1 (search for similar items in EconPapers)
Pages: 11 pages
Date: 2026-10-01
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Published in Heart Rhythm, 1, October, 2026, 23(10), pp. 2184 - 2194. ISSN: 1547-5271

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