Catheter ablation for treatment of atrial fibrillation in patients with heart failure with reduced ejection fraction: A systematic review and meta-analysis

Catheter ablation versus medical therapy in atrial fibrillation: an umbrella review of meta-analyses of randomized clinical trials

This umbrella review synthesizes data from 17 meta-analyses investigating the comparative outcomes of catheter ablation (CA) and medical treatment (MT) for atrial fibrillation (AF). Outcomes assessed were mortality, risk of hospitalization, AF recurrence, cardiovascular events, pulmonary vein stenosis, major bleeding, and changes in left ventricular ejection fraction (LVEF) and MLHFQ score. The findings indicate that CA significantly reduces overall mortality and cardiovascular hospitalization with high strength of evidence. The risk of AF recurrence was notably lower with CA, with moderate strength of evidence. Two associations reported an increased risk of pulmonary vein stenosis and major bleeding with CA, supported by high strength of evidence. Improved LVEF and a positive change in MLHFQ were also associated with CA. Among patients with AF and heart failure, CA appears superior to MT for reducing mortality, improving LVEF, and reducing cardiovascular rehospitalizations. In nonspecific populations, CA reduced mortality and improved LVEF but had higher complication rates. Our findings suggest that CA might offer significant benefits in managing AF, particularly in patients with heart failure. However, the risk of complications, including pulmonary vein stenosis and major bleeding, is notable. Further research in understudied populations may help refine these conclusions.

Optimal effectiveness of heart failure management - an umbrella review of meta-analyses examining the effectiveness of interventions to reduce (re)hospitalizations in heart failure

Heart failure (HF) is a major health concern, which accounts for 1-2% of all hospital admissions. Nevertheless, there remains a knowledge gap concerning which interventions contribute to effective prevention of HF (re)hospitalization. Therefore, this umbrella review aims to systematically review meta-analyses that examined the effectiveness of interventions in reducing HF-related (re)hospitalization in HFrEF patients. An electronic literature search was performed in PubMed, Web of Science, PsycInfo, Cochrane Reviews, CINAHL, and Medline to identify eligible studies published in the English language in the past 10 years. Primarily, to synthesize the meta-analyzed data, a best-evidence synthesis was used in which meta-analyses were classified based on level of validity. Secondarily, all unique RCTS were extracted from the meta-analyses and examined. A total of 44 meta-analyses were included which encompassed 186 unique RCTs. Strong or moderate evidence suggested that catheter ablation, cardiac resynchronization therapy, cardiac rehabilitation, telemonitoring, and RAAS inhibitors could reduce (re)hospitalization. Additionally, limited evidence suggested that multidisciplinary clinic or self-management promotion programs, beta-blockers, statins, and mitral valve therapy could reduce HF hospitalization. No, or conflicting evidence was found for the effects of cell therapy or anticoagulation. This umbrella review highlights different levels of evidence regarding the effectiveness of several interventions in reducing HF-related (re)hospitalization in HFrEF patients. It could guide future guideline development in optimizing care pathways for heart failure patients.

Impact of left atrial geometric remodeling on late atrial fibrillation recurrence after catheter ablation

AIMS

To quantitatively investigate the impact of left atrial geometric remodeling on atrial fibrillation recurrence after catheter ablation.

METHODS

A retrospective analysis of 105 patients with atrial fibrillation who underwent coronary computed tomographic angiography before catheter ablation. Risk factors for atrial fibrillation recurrence were identified by multivariable logistic regression analysis and used to create a nomogram.

RESULTS

After at least 12 months of follow-up, 30 patients (29%) developed recurrent atrial fibrillation. Patients with recurrence had higher left atrial volume, left atrial sphericity, and lower left atrial ejection fraction (LAEF) (P < 0.05). There was no significant difference in asymmetry index between the two groups (P = 0.121). Multivariable regression analysis showed that left atrial minimal volume index (LAVImin) [odds ratio (OR): 1.026, 95% confidence interval (CI): 1.002-1.050, P = 0.034], left atrial sphericity (OR: 1.222, 95% CI: 1.040-1.435, P = 0.015) and CHADS2 score (OR: 1.511, 95% CI: 1.024-2.229, P = 0.038) were independent predictors of atrial fibrillation recurrence. The combined model of the left atrial sphericity to the LAVImin substantially increased the predictive power for atrial fibrillation recurrence [area under the curve (AUC) = 0.736, 95% CI: 0.627-0.844, P < 0.001], with a sensitivity of 80% and a specificity of 61%. A nomogram was generated based on the contribution weights of the risk factors; the AUC was 0.772 (95% CI: 0.670-0.875) and had good internal validity.

CONCLUSION

The CHADS2 score, left atrial sphericity, and LAVImin were significant and independent predictors of atrial fibrillation recurrence after catheter ablation. Furthermore, the nomogram had a better predictive capacity for atrial fibrillation recurrence.

Left atrial fibrosis predicts left ventricular ejection fraction response after atrial fibrillation ablation in heart failure patients: the Fibrosis-HF Study

Aims

Atrial fibrillation (AF) and heart failure (HF) often coexist. Catheter ablation has been reported to restore left ventricular (LV) function but patients benefit differently. This study investigated the correlation between left atrial (LA) fibrosis extent and LV ejection fraction (LVEF) recovery after AF ablation.

Methods and results

In this study, 103 patients [64 years, 69% men, 79% persistent AF, LVEF 33% interquartile range (IQR) (25–38)] undergoing first time AF ablation were investigated. Identification of LA fibrosis and selection of ablation strategy were based on sinus rhythm voltage mapping. Continuous rhythm monitoring was used to assess ablation success. Improvement in post-ablation LVEF was measured as primary study endpoint. An absolute increase in post-ablation LVEF ≥10% was defined as ‘Super Response’. Left atrial fibrosis was present in 38% of patients. After ablation LVEF increased by absolute 15% (IQR 6–25) (P &lt; 0.001). Left ventricular ejection fraction improvement was higher in patients without LA fibrosis [15% (IQR 10–25) vs. 10% (IQR 0–20), P &lt; 0.001]. An inverse correlation between LVEF improvement and the extent of LA fibrosis was found (R2 = 0.931). In multivariate analysis, the presence of LA fibrosis was the only independent predictor for failing LVEF improvement [odds ratio 7.2 (95% confidence interval 2.2–23.4), P &lt; 0.001]. Echocardiographic ‘Super Response’ was observed in 55/64 (86%) patients without and 21/39 (54%) patients with LA fibrosis, respectively (P &lt; 0.001).

Conclusion

Presence and extent of LA fibrosis predict LVEF response in HF patients undergoing AF ablation. The assessment of LA fibrosis may impact prognostic stratification and clinical management in HF patients with AF.

Methodological and Clinical Heterogeneity and Extraction Errors in Meta-Analyses of Catheter Ablation for Atrial Fibrillation in Heart Failure

Background

Meta‐analyses are expected to follow a standardized process, and thus, they have become highly formulaic, although there is little evidence that such regimentation yields high‐quality results.

Methods and Results

This article describes the results of a critical examination of 14 published meta‐analyses of catheter ablation for atrial fibrillation in heart failure that were based on a nearly identical core set of 4 to 6 primary trials. Methodological issues included (1) the neglect of primary data or the failure to report any primary data; (2) the inaccurate recording of the number of randomized patients; (3) the lack of attention to data missingness or baseline imbalances; (4) the failure to contact investigators of primary trials for additional data; (5) the incorrect extraction of data, the misidentification of events, and the assignment of events to the wrong treatment groups; (6) the calculation of summary estimates based on demonstrably heterogenous data, methods of differing reliability, or unrelated end points; and (7) the development of conclusions based on sparse numbers of events or overly reliant on the results of 1 dominant trial.

Conclusions

These findings reinforce existing concerns about the methodological validity of meta‐analyses and their current status in the hierarchy of medical evidence, and they raise new questions about the process by which meta‐analyses undergo peer review by medical journals.