Catheter ablation of atrial fibrillation in patients with heart failure: can we break the vicious circle?

Catheter ablation in atrial fibrillation: is there a mortality benefit in patients with diabetes and heart failure?

Atrial fibrillation (AF) is the most commonly sustained arrhythmia, and patients with diabetes mellitus (DM) exhibit an increased incidence of AF. Besides DM, heart failure (HF) shares pathophysiological links with AF, mainly related to the pathological remodeling of hearts affected by structural disease. As in a vicious circle, AF may contribute to HF worsening and increased mortality in patients with structural heart diseases, and the outcome may be further impaired when concomitant DM is present. Although no data directly referring to DM patients with HF are available, indirect information can be drawn from large studies on patients with HF and AF. The present review discusses the outcome of AF ablation in patients with DM and HF, focusing on safety, efficacy, and most particularly on hard endpoints such as mortality and thromboembolic event incidence.

Conduction recovery following catheter ablation in patients with recurrent atrial fibrillation and heart failure

BACKGROUND

Atrial fibrillation (AF) catheter ablation is increasingly proposed for patients suffering from AF and concomitant heart failure (HF). However, the optimal ablation strategy remains controversial. We performed this study to assess the prevalence of pulmonary vein (PV) or linear lesion reconnection in HF patients undergoing repeated procedures.

METHODS AND RESULTS

At seven high-volume centres, 165 patients with HF underwent a repeat procedure after a first AF ablation including PV isolation alone (47 patients, group A) or PV isolation plus left atrial lines (118 patients, group B). Group A patients presented more often paroxysmal AF (p<0.001), less enlarged left atrium (p<0.001) and less left ventricular systolic dysfunction (p=0.031) compared to Group B, that more commonly had atypical atrial flutter (p<0.001). Forty-one (87%) patients in Group A and 69 (58%) in Group B presented at least one reconnected PV (p<0.001). Sixty-one (52%) patients in Group B presented at least one reconnected atrial line (left isthmus or roof). Patients without any reconnected PV (n=54, 33%) more frequently experienced persistent AF (p<0.001), had longer AF duration (p=0.047) and larger left atrial volume (p<0.001). Twenty-five patients (15%) with no PV and/or line reconnection did not significantly differ, concerning baseline characteristics, compared to those with at least one reconnected ablation site.

CONCLUSION

As in the general AF population undergoing catheter ablation, PV reconnection is frequent in patients with HF and symptomatic recurrence. However, one third of patients presented arrhythmic recurrences even in the absence of PV reconnection, highlighting the importance of the underlying atrial substrate.

Rosuvastatin reduces the recurrence rate following catheter ablation for atrial fibrillation in patients with heart failure

The aim of the present study was to assess whether rosuvastatin could reduce the recurrence rate of atrial fibrillation (AF) in patients with heart failure (HF) following catheter ablation (CA). A total of 107 patients with HF and AF who underwent CA of AF by endocardial mapping and radiofrequency between June 2012 and May 2014 were recruited. The patients were randomly divided into three subgroups: i) Administered with 10 mg rosuvastatin daily following ablation (group 1, n=36); ii) administered with 20 mg rosuvastatin daily following ablation (group 2, n=36); and iii) only treated with conventional treatment of HF following ablation (group 3, n=35). After the procedure, patients were followed in the outpatient clinic by interrogation of Holter monitoring. The AF recurrence rate of group 2 was low in comparison with group 1 (22.2% vs. 38.9%, P=0.013) and group 3 (22.2% vs. 48.6%, P=0.021). In comparison with baseline, the parameters of the left ventricular ejection fraction, left atrial diameter (LAD), and the levels of N-terminal pronatriuretic peptide and hypersensitive C-reactive protein (hs-CRP) were all improved in three groups. Furthermore, multivariate analysis demonstrated that LAD [hazard ratio (HR): 1.12, 95% confidence interval (CI): 1.06-1.67, P=0.049], hs-CRP (HR: 1.37, 95% CI: 1.11-1.92, P=0.002) and duration of AF (HR: 1.14, 95% CI: 1.09-1.18, P=0.011) were independent predictors of AF recurrence in patients with HF following CA. Therefore, the present study has demonstrated that treatment with 20 mg rosuvastatin daily following CA was able to significantly decrease the recurrence rate of AF in patients with HF, and LAD, hs-CRP, and duration of AF were independent predictors of AF recurrence in patients with HF following CA. In conclusion, the present study has also demonstrated that CA may improve cardiac function in patients with HF and AF.

Heart failure 2016: still more questions than answers

Heart failure has reached epidemic proportions given the ageing of populations and is associated with high mortality and re-hospitalization rates. This article reviews and summarizes recent advances in the diagnosis, assessment and treatment of the patients with heart failure. Data are discussed based also on the most recent guidelines indications. Open issues and unmet needs are highlighted.