Outcomes of patients with heart failure with preserved ejection fraction undergoing catheter ablation of atrial fibrillation

Effects of Atrial Fibrillation Ablation for Heart Failure With Preserved Ejection Fraction: Insights From CABANA

BACKGROUND

Atrial fibrillation (AF) ablation is Class I recommendation in selected heart failure (HF) patients with reduced ejection fraction; less is known in heart failure with preserved ejection fraction (HFpEF).

OBJECTIVES

The aim of this study was to investigate the effects of AF ablation in patients with HFpEF.

METHODS

The CABANA (Catheter Ablation vs Antiarrhythmic Drug Therapy for Atrial Fibrillation) trial randomized patients with cardiovascular risk factors for stroke to AF ablation vs drug therapy. The presence of a high likelihood of HFpEF at enrollment was determined by a modified H2FPEF score of ≥6. Treatment effects of baseline HFpEF likelihood on the AF ablation for death and cardiovascular admission, AF recurrence, and functional status were assessed.

RESULTS

A total of 1,763 patients were included in the analysis. A high modified H2FPEF score (55% of the entire cohort) resulted in a significant treatment effect modulation (P for interaction = 0.027), with a lower risk for cardiovascular hospitalization or death in patients with a high likelihood of HFpEF (HR: 0.82 [95% CI: 0.69-0.98]; P = 0.025), but not in patients without (HR: 1.00 [95% CI: 0.82-1.22]; P = 0.987). Although patients with a high likelihood of HFpEF were at a higher risk for AF recurrence, the greatest treatment effect of AF ablation on AF recurrence was observed in patients with a high likelihood of HFpEF (P for interaction = 0.035). In a sensitivity analysis in a subset of patients with echocardiographic evidence of HFpEF (n = 225), a similar treatment interaction was found.

CONCLUSIONS

In patients undergoing AF ablation, the presence of underlying HFpEF (either by HFpEF probability or defined by echocardiography) was associated with a larger benefit with AF ablation on clinical outcome, AF recurrence, and functional status. (Catheter Ablation vs Antiarrhythmic Drug Therapy for Atrial Fibrillation [CABANA]; NCT00911508).

Sex differences in atrial remodeling and atrial fibrillation recurrence after catheter ablation

BACKGROUND

Women undergoing catheter ablation (CA) for atrial fibrillation (AF) reportedly have higher recurrence rates despite being generally less prone to developing AF. It remains unclear whether these sex differences are primarily driven by intrinsic disparities in atrial remodeling or by a greater burden of comorbidities.

OBJECTIVES

The purpose of this study was to evaluate sex-specific differences in AF recurrence after CA, identify modifiers of the prognostic effect of sex, and evaluate atrial remodeling using new echocardiographic parameters.

METHODS

We retrospectively included patients undergoing first-time CA for AF. AF recurrence rates after an 8-week blanking period were compared between sexes. Baseline echocardiographic parameters of left atrial (LA) structure and function were assessed using volumetric and deformational indices and compared between sexes after propensity score (PS) matching.

RESULTS

The study included 560 patients (35% women) with a median follow-up of 19 months. Women were older (64 years vs 58 years; P<.001) and had more comorbidities than men. Women also exhibited a higher incidence of AF recurrence, both after adjusting for confounders (hazard ratio 1.75; 95% confidence interval 1.21-2.53) and after PS matching (hazard ratio 1.73; 95% confidence interval 1.05-2.87). Baseline characteristics did not modify the prognostic effect of sex on AF recurrence. In the PS-matched cohort of 113 patient pairs, women showed lower LA strain, increased LA stiffness, and more low-voltage areas, despite similar LA dimensions.

CONCLUSION

Female sex was an independent predictor of AF recurrence. After adjusting for confounders, women showed decreased LA strain and higher stiffness, suggesting intrinsic disparities in atrial remodeling that may explain their higher recurrence rates.

Adverse Events Requiring Hospitalization Following Catheter Ablation for Atrial Fibrillation in Heart Failure with versus without Systolic Dysfunction

BACKGROUND

The safety and efficacy of atrial fibrillation (AF) ablation in individuals with heart failure (HF) with preserved ejection fraction (EF), particularly concerning the occurrence of post-procedural adverse events necessitating hospitalization, including anticoagulant-associated major bleeding, still lack conclusive determination.

METHODS

Data from patients with HF and AF who underwent catheter ablation for AF between 2019 and 2022 at our institution were retrospectively reviewed. All participants were divided into an EF < 50% group or an EF ≥ 50% group according to their baseline left ventricular EF. The composite incidence of the clinical events following catheter ablation was compared between the two groups: (1) all-cause death, (2) HF hospitalization, (3) stroke or systemic embolism, and (4) major bleeding.

RESULTS

A total of 122 patients (75 years old, 68 male) were included. Of them, 62 (50.8%) patients had an EF ≥ 50%. EF ≥ 50% was an independent predictor of the composite endpoint (adjusted odds ratio 6.07, 95% confidence interval 1.37-26.99, p = 0.018). The incidences of each adverse event were not significantly different between the two groups, except for a higher incidence of major bleeding in the EF ≥ 50% group (12.7% vs. 0%, p = 0.026).

CONCLUSIONS

Among patients with HF coupled with AF, the incidence of adverse events following AF ablation proved notably elevated in patients with EF ≥ 50% in contrast to their counterparts with EF < 50%. This disparity primarily stems from a heightened occurrence of major bleeding within the EF ≥ 50% cohort. The strategy to reduce adverse events, especially in patients with EF ≥ 50%, remains the next concern.

Ablation for atrial fibrillation improves the outcomes in patients with heart failure with preserved ejection fraction

AIMS

Patients with heart failure with preserved ejection fraction (HFpEF) and atrial fibrillation (AF) have worse clinical outcomes than those with sinus rhythm (SR). We aim to investigate whether maintaining SR in patients with HFpEF through a strategy such as AF ablation would improve outcomes.

METHODS AND RESULTS

This is a cohort study that analysed 1034 patients (median age 69 [63-76] years, 46.2% [478/1034] female) with HFpEF and AF. Of these, 392 patients who underwent first-time AF ablation were assigned to the ablation group, and the remaining 642 patients, who received only medical therapy, were assigned to the no ablation group. The primary endpoint was a composite of all-cause death or rehospitalization for worsening heart failure. After a median follow-up of 39 months, the cumulative incidence of the primary endpoint was significantly lower in the ablation group compared to the no ablation group (adjusted hazard ratio [HR], 0.55 [95% CI, 0.37-0.82], P = 0.003) in the propensity score-matched model. Secondary endpoint analysis showed that the benefit of AF ablation was mainly driven by a reduction in rehospitalization for worsening heart failure (adjusted HR, 0.52 [95% CI, 0.34-0.80], P = 0.003). Patients in the ablation group showed a 33% relative decrease in atrial tachycardia/AF recurrence compared to the no ablation group (adjusted HR, 0.67 [95% CI, 0.54-0.84], P < 0.001).

CONCLUSION

Among patients with HFpEF and AF, the strategy of AF ablation to maintain SR was associated with a lower risk of the composite outcome of all-cause death or rehospitalization for worsening heart failure.

Catheter Ablation for Atrial Fibrillation in Structural Heart Disease: A Review

Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice. Patients with structural heart disease (SHD) are at an increased risk of developing this arrhythmia and are particularly susceptible to the deleterious hemodynamic effects it carries. In the last two decades, catheter ablation (CA) has emerged as a valuable strategy for rhythm control and is currently part of the standard care for symptomatic relief in patients with AF. Growing evidence suggests that CA of AF may have potential benefits that extend beyond symptoms. In this review, we summarize the current knowledge of this intervention on SHD patients.