A Compelling Case for Less Aggressive Arrhythmia Management in Patients With Chronic Heart Failure and Long-Standing Atrial Fibrillation

Predictors of Subsequent Heart Failure After Left Atrial Appendage Closure

BACKGROUND

Left atrial appendage occlusion (LAAO) plays an important role in preventing stroke in patients with atrial fibrillation. However, LAAO may interact unfavorably with left atrial (LA) compliance and reservoir function and thus increase the risk of heart failure (HF). The purpose of this study was to identify predictors of subsequent HF after successful LAAO.

METHODS AND RESULTS

A total of 98 patients (mean age 70±9 years, 68% male) who had undergone LAAO were included. The primary endpoint was unexpected HF admission after LAAO. During a mean period of 36±26 months, 16 of the 98 patients (16%) experienced hospital HF admission. In multivariate analysis, higher E/e' (hazard ratio [HR] 1.11, 95% confidence interval [CI] 1.02-1.20, P=0.014), higher left ventricular mass index (HR 1.02, 95% CI 1.00-1.03, P=0.023), history of HF (HR 4.78, 95% CI 1.55-14.7, P=0.006), and lower LA strain (HR 0.80, 95% CI 0.70-0.93, P=0.003) were independently associated with hospital HF admission. Patients with LAAO had a significantly higher incidence of subsequent HF than the control group after propensity score matching (P=0.046).

CONCLUSIONS

LAAO increases the occurrence of HF, and it is not uncommon after successful LAAO. A previous history of HF, left ventricular mass index, E/e', and abnormal LA strain are independently associated with the development of HF. These parameters should be considered before attempting LAAO.

Current Management Strategies in Patients with Heart Failure and Atrial Fibrillation: A Review of the Literature

Heart Failure (HF) and Atrial Fibrillation (AF) are common diseases which lead to significant morbidity and mortality. Each disease can be a challenge to treat clinically, especially when they present together. We performed a review of the literature including clinical trials, metanalyses, and guidelines regarding the management of patients with HF and AF. This review describes the pathophysiologic mechanisms behind each disease state, their associated prognosis, and epidemiologic features. Strategies for prevention of stroke in patients with AF, including use of novel oral anticoagulants as well as prevention of the development of AF are discussed. We review the medical and catheter-based therapies for AF and present an original algorithm for the management of AF in patients with HF.

Association of the H2FPEF Risk Score with Recurrence of Atrial Fibrillation Following Pulmonary Vein Isolation

Background

While atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF) commonly coexist, the efficacy of pulmonary vein isolation in the setting of HFpEF is unclear.

Methods

In a cohort of patients who underwent cryoballoon ablation (CBA) from 2011 to 2016, we calculated the H₂FPEF risk score, a novel 6-item score (scale: 0-9 points) that accurately predicts the probability of HFpEF. We compared characteristics of patients by H₂FPEF score and evaluated the association of H₂FPEF score with 12-month recurrence of AF post-procedure.

Results

Of patients with available data to calculate the H₂FPEF score (n=105), the median H₂FPEF score was 5 (interquartile range: 4-6), corresponding to >80% probability of HFpEF. Compared to patients with H₂FPEF scores ≤4 (n=34), patients with H₂FPEF scores of 5 and 6 (n=46) and ≥7 (n=25) carried higher rates of hypertension (≤4: 21% vs. 5 and 6: 63% vs. ≥7: 88%, P<0.001) and diabetes (≤4: 0% vs. 5 and 6: 9% vs. ≥7: 32%, P=0.001). The overall 12-month recurrence rate of AF was 21%. There was no association between H₂FPEF score and recurrence of AF at 12 months (OR per SD increase in log-H₂FPEF score: 0.87, 95% CI: 0.54-1.40, P=0.57).

Conclusions

Among patients undergoing CBA for AF, median H₂FPEF scores are elevated, and screening for occult HFpEF may be warranted in this population. There was no association of the H₂FPEF score and AF recurrence at 12 months, suggesting efficacy of CBA even among patients with high H₂FPEF scores.