Catheter ablation for patients with atrial fibrillation and heart failure with reduced and preserved ejection fraction: insights from the KiCS-AF multicentre cohort study

Impact of Obesity on Short-Term Outcomes Following Catheter Ablation for Atrial Fibrillation in Patients with Heart Failure

This study aimed to evaluate the impact of obesity on in-hospital outcomes of patients with HF undergoing AF catheter ablation. This population-based, retrospective observational study extracted data from the US Nationwide Inpatient Sample (NIS) database 2005-2018. Patients ≥ 20 years with HF and undergoing catheter ablation for AF were eligible for inclusion. Propensity-score matching (PSM) was utilized to balance the baseline characteristics between obese and non-obese groups. Univariate and multivariable regression analyses were used to determine the associations between obese status and other variables with the in-hospital outcomes. These outcomes included non-home discharge, prolonged length of stay (LOS), complications, and a composite outcome that encompassed these outcomes along with in-hospital mortality. A total of 18,751 patients were included. After PSM, 8,014 patients remained in the study sample. The mean age was 64.6 ± 0.1 years. After adjustment, significant association was detected between obesity and greater odds of non-home discharge (adjusted odd ratio [aOR] = 1.18), prolonged LOS (aOR = 1.18), complications (aOR = 1.30), respiratory failure/mechanical ventilation (aOR = 1.56) and acute kidney injury (AKI) (aOR = 1.28), central nervous system and peripheral neuropathy (aOR = 1.33), and transient ischemic attack (aOR = 8.16), as well as poor composite outcome (aOR = 1.28) compared with non-obese patients. In US patients with HF undergoing AF catheter ablation, obesity is associated with a higher risk for non-home discharge, prolonged LOS, and several major complications. Clinicians should exercise heightened vigilance when administering therapy to this subgroup of patients.

Safety and efficacy of catheter ablation in atrial fibrillation patients with heart failure with preserved ejection fraction

PURPOSE

Catheter ablation (CA) for atrial fibrillation (AF) in heart failure patients with preserved ejection fraction (HFPEF) has shown promising results in reducing mortality and improving heart function. However, previous studies have been limited by a lack of control groups and significant heterogeneity in their methodologies.

HYPOTHESIS

CA for AF in HFPEF patients may not increase the complications and had similarly the rate of freedom from AF vs. patients without HFPEF, and it may reduce hospitalizations and mortality and improve heart function VS medical treatment.

METHODS

Three groups of AF patients were included in the study: 187 patients with HFPEF for their first CA (AFPHF-CA), 187 patients with HFPEF who were undergoing medical therapy (AFPHF-Med), and 196 patients without HFPEF for their first CA (AF-CA).

RESULTS

After a mean (± SD) follow-up of 36 ± 3 months, 50.8% of patients in the AFPHF-CA group and 52.0% in the AF-CA group remained in sinus rhythm (P = 0.94), compared to only 12.5% in the AFPHF-Med group (P < 0.001). Age (OR: 1.09, 95% CI: 1.02-1.08, P = 0.016), duration of AF history (OR: 1.01, 95% CI: 1.00-1.02, P = 0.017), left atrial diameter (OR: 1.52, 95% CI: 1.06-2.19, P = 0.024), and the type of atrial fibrillation (OR: 4.02, 95% CI: 1.28-12.62, P = 0.017) were consistent multivariable predictors for sinus rhythm maintenance in AFPHF. HF hospitalization was significantly lower in the AFPHF-CA group (0.38 (0,2)) than in the AFPHF-Med group (1.28(0,3), P < 0.001) during the follow-up. Stroke occurred in 18 of 187 (9.63%) patients in the AFPHF-CA group, significantly lower than the AFPHF-Med group, with approximately 31 of 187 (16.58%) (P < 0.01), but not statistically different from AF-CA, where approximately 17 of 196 (8.67%) experienced stroke (P = 0.65). Regarding mortality, death occurred in 12.8% of patients in the AFPHF-Med group, higher than 7.5% in the AFPHF-CA group and 6.6% in the AF-CA group (P = 0.49). Significant improvements in heart function were observed in the AFPHF-CA group compared to the AFPHF-Med group, including reductions in left ventricular end-diastolic diameter (P < 0.001), New York Heart Association classification (P < 0.001), left ventricular mass index (P < 0.001), and left atrial volume index (P < 0.001). HF hospitalization was significantly lower in the AFPHF-CA group compared to AFPHF-Med (P < 0.001).

CONCLUSION

CA for AF has showed significant benefits in patients with HFPEF compared to medical treatment alone. These benefits include improvements in heart function, reduced mortality, incidence of stroke, and hospitalizations. Importantly, CA in HFPEF patients showed comparable maintenance of sinus rhythm (SR) and safety outcomes when compared to CA in individuals with normal heart function.

Clinical Outcomes of Catheter Ablation for Atrial Fibrillation in Patients with Acute Decompensated Heart Failure

Background: The prognosis of acute decompensated heart failure (ADHF) and heart failure (HF) with atrial fibrillation (AF) has been dismal. This study was performed to investigate the clinical outcomes of catheter ablation (CA) performed in patients with concurrent ADHF and AF. Methods: We retrospectively analyzed ADHF patients with AF who were admitted to our institution from 2007 to 2017. Results: In total, 472 patients were included in this study, with a mean follow-up duration of 32.8 ± 32.9 months. The 5-year event-free rate (cardiovascular death and HF hospitalization) was 61.4%, and the 10-year event-free rate was 42.7%. A comparative analysis of the event group and control group revealed that patients in the event group were older (event group vs. control group: 72.1 ± 11.0 vs. 68.8 ± 13.4 years, p = 0.008) and had a higher proportion of Clinical Scenario 3 classifications (event group vs. control group: 24% vs. 12%, p = 0.001). Notably, patients in the event group had a lower sinus rhythm maintenance rate (event group vs. control group: 17% vs. 31%, p < 0.001) and CA rate (event group vs. control group: 9% vs. 21%, p = 0.003). The CA group had a higher event-free rate than the non-CA group, and this trend persisted even after matching the patients' backgrounds (log-rank test: p < 0.001). Conclusions: Patients presenting with AF at the onset of ADHF showed a poor prognosis, whereas CA demonstrated potential for improving the prognosis for some of these patients.

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society.

Sex differences in atrial fibrillation ablation outcomes in patients with heart failure

BACKGROUND

There is a lack of data on the impact of sex on the outcomes of patients with heart failure (HF) undergoing atrial fibrillation (AF) ablation. We aimed to analyze the association of sex with outcomes of atrial fibrillation ablation in patients with heart failure.

METHODS

The National Readmissions Database (NRD) was analyzed from 2016 to 2019 to identify patients ≥ 18 years old with heart failure (HF) undergoing AF ablation. The outcomes of interest included peri-procedural complications, in-hospital mortality, resource utilization, and unplanned 1-year readmissions. The final cohort was divided into patients with HFrEF and HFpEF and outcomes were compared between males and females in both cohorts.

RESULTS

A total of 23,277 patients with HF underwent AF ablation between 2016 and 2019, of which 14,480 had HFrEF and 8,797 had HFpEF. Among patients with HFrEF, 61.6% were males and 38.4% were females whereas, among patients with HFpEF, 35.4% were males and 64.6% were females. On a multivariable-adjusted analysis, in patients with HFrEF, there was no difference in the odds of in-hospital mortality, peri-procedural complications, or 1-year HF-related/AF-related/all-cause readmissions between males and females. In patients with HFpEF, females had a higher risk 1-year HF-related readmissions (adjusted hazards ratio: 1.46; 95% CI: 1.13-1.87; p = 0.01), without any difference in the 1-year AF-related/all-cause readmissions, in-hospital mortality, or peri-procedural complications.

CONCLUSION

Our results show that females with HFrEF undergoing AF ablation have similar outcomes whereas females with HFpEF have higher 1-year HF readmissions with no difference in the other outcomes, compared to males.

The Impact of Frailty on Patients With AF and HFrEF Undergoing Catheter Ablation: A Nationwide Population Study

Background

Frailty is a common geriatric syndrome often coexisting with cardiovascular diseases such as atrial fibrillation (AF) and heart failure (HF) with reduced ejection fraction (HFrEF). While catheter ablation (CA) has demonstrated efficacy in reducing major adverse cardiovascular events and improving mortality and quality of life, the influence of frailty among this population remains unknown.

Objectives

The authors aimed to identify the prevalence of frailty among patients with HFrEF and AF undergoing CA and its influence on cardiovascular mortality and discharge disposition.

Methods

From January 2016 to December 2019, we used the Nationwide Inpatient Sample to identify patients with AF and HFrEF. Frailty was identified by the presence of ≥1 diagnostic cluster utilizing the Johns Hopkins Adjusted Clinical Groups with malnutrition, dementia, impaired vision, decubitus ulcer, urinary incontinence, loss of weight, poverty, barriers to access to care, difficulty walking, and falls as indicators. We compared clinical outcomes among frail vs nonfrail patients, including all-cause in-hospital mortality, major adverse cardiovascular events, other major complications, discharge disposition, and hospital length of stay using multivariable regression analysis.

Results

Of 113,115 weighted admissions, 11,725 (10.4%) were classified as frail. Frail patients were older (median age: 76 [IQR: 15] years vs 70 [IQR: 15] years, P < 0.001) than nonfrail patients. Frailty was associated with increased odds of all-cause hospital mortality (adjusted odds ratio [aOR]: 2.64; 95% CI: 1.87-3.72; P < 0.001), major adverse cardiovascular events (aOR: 2.00; 95% CI: 1.62-2.47; P < 0.001), and nonhome discharge (aOR: 3.31; 95% CI: 2.78-3.94; P < 0.001). Frail patients also experienced longer hospital length of stay (median 9 [IQR: 10] days vs 5 [IQR: 5] days, P < 0.001) after adjustment by Poisson regression (coefficient: 0.53; 95% CI: 0.46-0.59; P < 0.001).

Conclusions

Frailty is associated with worse outcomes in patients with HFrEF undergoing CA for AF. The integration of frailty models in clinical practice may facilitate prognostication and risk stratification to optimize patient selection for CA.

Varying effect of atrial fibrillation ablation in patients with heart failure with preserved ejection fraction according to CHA2DS2-VASc score

BACKGROUND

The impact of comorbidity burden on outcomes of radiofrequency catheter ablation (RFCA) for atrial fibrillation (AF) in patients with heart failure and preserved ejection fraction (HFpEF) remains unclear.

OBJECTIVE

The purpose of this study was to evaluate how comorbidity burden influences the association between RFCA and cardiovascular outcomes in AF patients with HFpEF.

METHODS

AF patients with HFpEF from the prospective China-AF cohort, recruited between August 2011 and December 2020, were categorized into 2 groups based CHA2DS2-VASc score: low comorbidity burden (score ≤4) and high comorbidity burden (score >4). The associations between RFCA and cardiovascular outcomes and interaction effects of comorbidity burden on these associations were assessed.

RESULTS

Among 1700 patients with median follow-up of 65.9 months, those in the low comorbidity burden group who received RFCA had a lower risk of composite events (cardiovascular death and ischemic stroke/transient ischemic attack [TIA]) (adjusted hazard ratio [HR] 0.35, 95% confidence interval [CI] 0.21-0.59] and all-cause death (adjusted HR 0.31, 95% CI 0.17-0.54) compared to those without RFCA. However, significant associations were not observed in the high comorbidity burden group. The differences between low and high comorbidity burden groups were significant, with interaction effects noted between comorbidity burden and RFCA for cardiovascular death (Pinteraction = 0.045) and ischemic stroke/TIA (Pinteraction = 0.010). RFCA was associated with a reduced risk of AF recurrence in both comorbidity burden groups.

CONCLUSION

RFCA for AF is associated with reduced AF recurrence and improved cardiovascular outcomes in patients with HFpEF. However, these benefits may be limited for patients with a CHA2DS2-VASc score >4 (high comorbidity burden).

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society (HRS), the Asia Pacific HRS, and the Latin American HRS.

Efficacy and safety of catheter ablation for atrial fibrillation in patients with heart failure with preserved ejection fraction: a systematic review and meta-analysis

Background

Catheter ablation (CA) effectively treats atrial fibrillation (AF) in heart failure (HF) with reduced ejection fraction (HFrEF), improving clinical outcomes. However, its benefits for AF patients with heart failure with preserved ejection fraction (HFpEF) are still unclear.

Methods

We systematically searched PubMed, Embase, Web of Science, the Cochrane Library, and Scopus for studies investigating outcomes of CA in AF patients with HFpEF. Efficacy indicators included freedom from AF and antiarrhythmic drugs (AAD) free AF elimination. Safety indicators comprised total complications, HF admission, all-cause admission, and all-cause mortality. Sixteen studies with 20,796 patients included in our research.

Results

The comprehensive analysis demonstrated that, when comparing CA with medical therapy in HFpEF, no significant differences were observed in terms of HF admissions, all-cause admissions, and all-cause mortality [(OR: 0.42; 95% CI: 0.12-1.51, P = 0.19), (HR: 0.78; 95% CI: 0.48-1.27, P = 0.31), and (OR: 1.10; 95% CI: 0.83-1.44, P = 0.51)], while freedom from AF was significantly higher in CA (OR: 5.88; 95% CI: 2.99-11.54, P < 0.00001). Compared with HFrEF, CA in HFpEF showed similar rates of freedom from AF, AAD-free AF elimination, total complications, and all-cause admission were similar [(OR:0.91; 95% CI: 0.71,1.17, P =0.47), (OR: 0.97; 95% CI: 0.50-1.86, P = 0.93), (OR: 1.27; 95% CI: 0.47-3.41, P = 0.64), (OR: 1.11; 95% CI: 0.72, 1.73; P = 0.63)]. However, CA in HFpEF was associated with lower rates of HF admission and all-cause mortality [(OR: 0.35; 95% CI: 0.20, 0.60; P = 0.0002), (OR: 0.40; 95% CI: 0.18, 0.85; P = 0.02)]. Compared with patients without HF, CA in HFpEF patients exhibited lower rates of AAD-free AF elimination (OR: 0.48; 95% CI: 0.30, 0.75; P = 0.001). However, their rates of freedom from AF and total complications were similar [(OR: 0.70; 95% CI: 0.48, 1.02; P = 0.06), (OR: 0.60; 95% CI: 0.19, 1.90; P = 0.38)].

Conclusion

This meta-analysis conducted provided a comprehensive evaluation of the efficacy and safety of CA in patients with AF and HFpEF. The results suggest that CA may represent a valuable treatment strategy for patients with AF and HFpEF.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/#recordDetails, identifier (CRD42024514169).

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society .

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.

Atrial Fibrillation can adversely impact Heart Failure with Preserved Ejection Fraction by its association with Heart Failure Progression and Mortality: A Post-Hoc Propensity Score-Matched Analysis of the TOPCAT Americas Trial

AIMS

Prevalent atrial fibrillation (AF) is associated with excess cardiovascular (CV) death (D) and hospitalizations (H) in heart failure (HF) with preserved ejection fraction (pEF). We evaluated if it had an independent role in excess CVD in HFpEF and studied its impact on cause-specific mortality and HF morbidity.

METHODS AND RESULTS

We used propensity score-matched (PSM) cohorts from the TOPCAT Americas trial to account for confounding by other co-morbidities. Two prevalent AF presentations at study entry were compared: (i) subjects with Any AF event by history or on electrocardiogram (ECG) with PSM subjects without an AF event and (ii) subjects in AF on ECG with PSM subjects in sinus rhythm. We analyzed cause-specific modes of death and HF morbidity during a mean follow-up period of 2.9 years. A total of 584 subjects with Any AF event and 418 subjects in AF on ECG were matched. Any AF was associated with increased CVH [hazard ratio (HR) 1.33, 95% confidence interval (CI) 1.11-1.61, P = 0.003], HFH (HR 1.44, 95% CI 1.12-1.86, P = 0.004), pump failure death (PFD) (HR 1.95, 95% CI 1.05-3.62, P = 0.035), and HF progression from New York Heart Association (NYHA) classes I/II to III/IV (HR 1.30, 95% CI 1.04-1.62, P = 0.02). Atrial fibrillation on ECG was associated with increased risk of CVD (HR 1.46, 95% CI 1.02-2.09, P = 0.039), PFD (HR 2.21, 95% CI 1.11-4.40, P = 0.024), and CVH and HFH (HR 1.37, 95% CI 1.09-1.72, P = 0.006 and HR 1.65, 95% CI 1.22-2.23, P = 0.001, respectively). Atrial fibrillation was not associated with risk of sudden death. Both Any AF and AF on ECG cohorts were associated with PFD in NYHA class III/IV HF.

CONCLUSION

Prevalent AF can be an independent risk factor for adverse CV outcomes by its selective association with worsening HF, HFH, and PFD in HFpEF. Prevalent AF was not associated with excess sudden death risk in HFpEF. Atrial fibrillation was also associated with HF progression in early symptomatic HFpEF and PFD in advanced HFpEF.

TRIAL REGISTRATION

TOPCAT trial is registered at www.clinicaltrials.gov:identifier NCT00094302.

Catheter ablation improved ejection fraction in persistent AF patients: a DECAAF-II sub analysis

AIMS

The aim of our study was to assess differences in post-ablation atrial fibrillation (AF) recurrence and burden and to quantify the change in LVEF across different congestive heart failure (CHF) subcategories of the DECAAF-II population.

METHODS AND RESULTS

Differences in the primary outcome of AF recurrence between CHF and non-CHF groups was calculated. The same analysis was performed for the three subgroups of CHF and the non-CHF group. Differences in AF burden after the 3-month blanking period between CHF and non-CHF groups was calculated. Improvement in LVEF was calculated and compared across the three CHF groups. Improvement was also calculated across different fibrosis stages. There was no significant differences in AF recurrence and AF burden after catheter ablation between CHF and non-CHF patients and between different CHF subcategories. Patients with heart failure with reduced ejection fraction (HFrEF) experienced the greatest improvement in EF following catheter ablation (CA, 16.66% ± 11.98, P < 0.001) compared to heart failure with moderately reduced LVEF, and heart failure with preserved EF (10.74% ± 8.34 and 2.00 ± 8.34 respectively, P-value < 0.001). Moreover, improvement in LVEF was independent of the four stages of atrial fibrosis (7.71 vs. 9.53 vs. 5.72 vs. 15.88, from Stage I to Stage IV respectively, P = 0.115).

CONCLUSION

Atrial fibrillation burden and recurrence after CA is similar between non-CHF and CHF patients, independent of the type of CHF. Of all CHF groups, those with HFrEF had the largest improvement in LVEF after CA. Moreover, the improvement in ventricular function seems to be independent of atrial fibrosis in patients with persistent AF.