A randomized ablation-based atrial fibrillation rhythm control versus rate control trial in patients with heart failure and high burden atrial fibrillation: The RAFT-AF trial rationale and design

Efficacy of catheter ablation for atrial fibrillation in heart failure: a meta-analysis of randomized controlled trials

The study aims to evaluate whether rhythm control by catheter ablation is superior to medical therapy for the patients with atrial fibrillation (AF) and heart failure (HF). The literatures were searched by using PubMed, Cochrane Library, Embase, and Web of Science databases up to 12 October 2023. The randomized controlled trials (RCTs) comparing rhythm control using catheter ablation vs. medical therapy in AF patients with HF were pooled. The primary outcomes included all-cause mortality, HF re-hospitalization, and stroke, and the secondary outcomes included left ventricular ejection fraction (LVEF), atrial tachyarrythmia recurrence, quality of life (Minnesota Living with Heart Failure Questionnaire score, MLHFQ score), 6 min walking distance (6MWD), the level of N-terminal B-type natriuretic peptide precursor (NT-proBNP), and adverse events. Nine RCTs involving in 2293 patients met the inclusion criteria. Compared with medical therapy, catheter ablation reduced all-cause mortality [10.07% (121/1201) vs. 15.26% (175/1147), risk ratio (RR):0.60, 95% confidence interval (CI): 0.48-0.74, P < 0.00001, I2 = 0%] and the rate of HF re-hospitalization (RR: 0.65, P = 0.02, 95% CI: 0.45 to 0.94, I2 = 74%), but had no obvious difference in incidence of stroke (RR: 0.67, P = 0.27, 95% CI: 0.32 to 1.38, I2 = 0%). Catheter ablation enhanced LVEF [mean difference (MD), 6.26%, P < 0.00001, I2 = 89%], reduced AT recurrence (RR: 0.37, P < 0.00001, 95% CI: 0.26 to 0.52, I2 = 89%), improved the quality of life (MLHFQ score) (MD: -6.83, P = 0.003, I2 = 67%), elevated 6MWD (MD: 15.92, P = 0.006, I2 = 76%), and diminished the level NT-proBNP (MD: -44.19, P < 0.00001, I2 = 75%), but had no significant difference in adverse events [25.81% (310/1201) vs. 30.25% (347/1147), RR: 0.81, 95% CI: 0.65-1.01, P = 0.06, I2 = 55%]. Catheter ablation as rhythm control strategy substantially enhances the survival rate, reduces HF re-hospitalization, increases the rate of sinus rhythm maintenance, improves the left ventricular function and the quality of life for AF patients with HF, and has similar safety, compared with medical therapy. The rhythm control by catheter ablation may be a better strategy for the AF patients with HF.

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.

Development and validation of a prediction model for in-hospital death in patients with heart failure and atrial fibrillation

BACKGROUND

To develop a prediction model for in-hospital mortality of patients with heart failure (HF) and atrial fibrillation (AF).

METHODS

This cohort study extracted the data of 10,236 patients with HF and AF upon intensive care unit (ICU) from the Medical Information Mart for Intensive Care (MIMIC). The subjects from MIMIC-IV were divided into the training set to construct the prediction model, and the testing set to verify the performance of the model. The samples from MIMIC-III database and eICU-CRD were included as the internal and external validation set to further validate the predictive value of the model, respectively. Univariate and multivariable Logistic regression analyses were used to explore predictors for in-hospital death in patients with HF and AF. The receiver operator characteristic (ROC), calibration curves and the decision curve analysis (DCA) curves were plotted to evaluate the predictive values of the model.

RESULTS

The mean survival time of participants from MIMIC-III was 11.29 ± 10.05 days and the mean survival time of participants from MIMIC-IV was 10.56 ± 9.19 days. Simplified acute physiology score (SAPSII), red blood cell distribution width (RDW), beta-blocker, race, respiratory rate, urine output, coronary artery bypass grafting (CABG), Charlson comorbidity index, renal replacement therapies (RRT), antiarrhythmic, age, and anticoagulation were predictors finally included in the prediction model. The AUC of our prediction model was 0.810 (95%CI: 0.791-0.828) in the training set, 0.757 (95%CI: 0.729-0.786) in the testing set, 0.792 (95%CI: 0.774-0.810) in the internal validation set, and 0.724 (95%CI: 0.687-0.762) in the external validation set. The calibration curves of revealed that the predictive probabilities of our model for the in-hospital death in patients with HF and AF deviated slightly from the ideal model. The DCA curves revealed that the use of our prediction model increased the net benefit than use no model.

CONCLUSION

The prediction model had good discriminative ability, and might provide a tool to timely identify patients with HF complicated with AF who were at high risk of in-hospital mortality.

Cryoballoon ablation for atrial fibrillation in patients with heart failure with mildly reduced and preserved ejection fraction

AIMS

Limited data are available on the outcomes of cryoballoon ablation (CBA)-based pulmonary vein isolation (PVI) for atrial fibrillation (AF) in patients with heart failure (HF) with preserved ejection fraction (HFpEF) and mildly reduced ejection fraction (HFmrEF). The present study aimed to evaluate the safety and effectiveness of CBA in such patients.

METHODS AND RESULTS

Consecutive patients with AF referred for CBA-based PVI from two highly experienced electrophysiology centres were included in this retrospective study. Of 651 patients undergoing CBA, 471 cases were divided into four groups: No HF (n = 255), HFpEF (n = 101), HFmrEF (n = 78), and HF with reduced ejection fraction (n = 37). Similar early recurrence of atrial arrhythmia was found among groups (16.2% vs. 15.4% vs. 14.9% vs. 12.2%, P = 0.798), and no significant difference of long-term sinus rhythm (SR) maintenance was identified among the HFmrEF, HFpEF, and No HF groups (71.8% vs. 75.2% vs. 79.6%, P = 0.334). CBA is safe for patients with HFmrEF and HFpEF with similar complications compared with the No HF group (3.8% vs. 4.0% vs. 3.1%, P = 0.814). The reassessment of cardiac function after CBA showed that patients with HF indicated beneficial outcomes. Left atrial diameter (LAD) and left ventricular ejection fraction were significantly improved in the HFmrEF group. There were 41.6% of patients in the HFpEF group who were completely relieved from HF. LAD and New York Heart Association (NYHA) were associated with recurrence in the HFpEF and HFmrEF groups, and the maintenance of SR was an independent predictor of NYHA improvement for all HF groups.

CONCLUSIONS

Patients with HFmrEF and HFpEF could benefit from CBA with high SR maintenance and significant HF improvement.

Effect of concomitant surgical atrial fibrillation ablation in patients with reduced left ventricle ejection fraction: A propensity-score matching analysis

BACKGROUND

Atrial fibrillation (AF) is common in patients with reduced left ventricle ejection fraction (RLVEF). The impact of concomitant surgical atrial fibrillation ablation (SAFA) in patients with RLVEF is uncertain. The purpose of this study was to assess the outcomes of concomitant SAFA in patients with RLVEF undergoing heart surgery on heart failure (HF) rehospitalization and mortality.

METHODS

Using a local registry and electronic health records linked with provincial civil register survival data from July 2002 to April 2019, we analyzed treatment and outcomes in a cohort of patients with AF and HF defined by left ventricle ejection fraction (LVEF) ≤40%. Health records were used to collect treatment and International Classification of Diseases (ICD 10) codes to determine outcomes. A negative binomial model was used to compare outcomes such as all-cause mortality and rehospitalization for heart failure.

RESULTS

The cohort included 682 patients with RLVEF and AF who underwent coronary artery bypass graft and/or valve surgery. A total of 196 patients (29%) underwent concomitant SAFA. After matching, 132 patients with concomitant SAFA were compared to 159 patients who did not undergo concomitant SAFA. At 6.0 ± 3.7 years of follow-up, concomitant SAFA was not associated with lower all-cause mortality (p = .9861) and reduction in rehospitalizations for heart failure decompensation (p = .31) compared to patients who did not have concomitant SAFA performed. Postoperatively, concomitant SAFA might be associated with less vasopressor and mechanical support use (p = .01).

CONCLUSIONS

Concomitant SAFA during index cardiac surgery is safe but does not reduce mortality or rehospitalizations for HF. The effects of concomitant SAFA in the context of RLVEF need to be better studied with prospective trials.

Management of Atrial Fibrillation Across the Spectrum of Heart Failure With Preserved and Reduced Ejection Fraction

Atrial fibrillation (AF) is the most common arrhythmia among patients with heart failure (HF), and HF is the most common cause of death for patients presenting with clinical AF. AF is frequently associated with pathological atrial myocardial dysfunction and remodeling, a triad that has been called atrial myopathy. AF can be the cause or consequence of clinical HF, and the directionality varies between individual patients and across the spectrum of HF. Although initial trials suggested no advantage for a systematic rhythm control strategy in HF with reduced ejection fraction, recent data suggest that select patients may benefit from attempts to maintain sinus rhythm with catheter ablation. Preliminary data also show a close relationship among AF, left atrial myopathy, mitral regurgitation, and HF with preserved ejection, with potential clinical benefits to catheter ablation therapy. The modern management of AF in HF also requires consideration of the degree of atrial myopathy and chronicity of AF, in addition to the pathogenesis and phenotype of the underlying left ventricular HF. In this review, we summarize the contemporary management of AF and provide practical guidance and areas in need of future investigation.

Pharmacologic Rate versus Rhythm Control for Atrial Fibrillation in Heart Failure Patients

Atrial fibrillation (AF) and Heart failure (HF) constitute two frequently coexisting cardiovascular diseases, with a great volume of the scientific research referring to strategies and guidelines associated with the best management of patients suffering from either of the two or both of these entities. The common pathophysiological paths, the adverse outcomes, the hospitalization rates, and the mortality rates that occur from various reports and trials indicate that a targeted therapy to the common background of these cardiovascular conditions may reverse the progression of their interrelating development. Among other optimal treatments concerning the prevalence of both AF and HF, the introduction of rhythm and rate control strategies in the guidelines has underlined the importance of sinus rhythm and heart rate control in the prevention of deleterious complications. The use of these strategies in the clinical practice has led to a debate about the superiority of rhythm versus rate control. The current guidelines as well as the published randomized trials and studies have not proved that rhythm control is more beneficial than the rate control treatments in the terms of survival, all-cause mortality, hospitalization rates, and quality of life. Therefore, the current therapeutic strategy is based on the therapy guidelines and the clinical judgment and experience. The aim of this review was to elucidate the endpoints of pharmacologic randomized clinical trials and the clinical data of each antiarrhythmic or rate-limiting medication, so as to promote their effective, individualized, evidence-based clinical use.

Heart failure and catheter ablation of atrial fibrillation: Navigating the difficult waters of heart failure phenotypes

The use of catheter ablation of atrial fibrillation (AFA) is increasing and it has now been extended to include higher risk patients with heart failure (HF), based on evidence from observational studies and meta-analyses of randomized controlled trials (RCTs) indicating it as safe and beneficial in terms of quality of life, AF recurrence and hospital readmissions in the short-to-middle term. However, the RCTs so far have been relatively small with short follow-up, and few larger trials with long follow-up inconclusive about hard outcomes for large patient crossover undermining the robustness of the results. Importantly, most RCTs involved HF patients with reduced left ventricular ejection fraction (HFrEF). In contrast, most observational studies show that the majority of ablated HF patients in clinical practice have a preserved ejection fraction (HFpEF), a condition representing roughly half of all HF patients. This article provides an overview of the available scientific evidence in this clinical field and examines the current guideline recommendations. In the absence of robust evidence-based research, the recommendations on AFA in HF may be inconsistent or abstain from taking firm positions, particularly regarding AFA in HFpEF. There is need for clinical research in such a surprisingly orphan setting, in parallel with the current attempts to sort out the knotty question of the HF phenotypes, in particular, again, of the HFpEF phenotypes.

Randomized Ablation-Based Rhythm-Control Versus Rate-Control Trial in Patients with Heart Failure and Atrial Fibrillation: Results from the RAFT-AF trial

Background: Atrial fibrillation (AF) and heart failure (HF) frequently coexist and can be challenging to treat. Pharmacologic based rhythm-control of AF has not proven to be superior to rate-control. Ablation-based rhythm-control was compared to rate-control to evaluate if clinical outcomes in patients with HF and AF could be improved. Methods: This was a multicenter, open-label trial with blinded outcome evaluation using a central adjudication committee. Patients with high burden paroxysmal (>4 episodes in six months) or persistent (duration < three years) AF, New York Heart Association class II-III HF, and elevated NT-proBNP were randomized to ablation-based rhythm-control or rate-control. The primary outcome was a composite of all-cause mortality and all HF events, with a minimum follow up of two years. Secondary outcomes included left ventricular ejection fraction (LVEF), six-minute walk test and NT-proBNP. Quality of life was measured using the Minnesota Living with Heart Failure Questionnaire (MLHFQ) and the AF Effect on quality of life (AFEQT). The primary analysis was time-to-event using Cox proportional hazards modeling. The trial was stopped early due to a determination of apparent futility by the Data Safety Monitoring Committee. Results: From December 1, 2011, to January 20, 2018, 411 patients were randomized to ablation-based rhythm-control (n=214) or rate-control (n=197). The primary outcome occurred in 50 (23.4%) patients in the ablation-based rhythm-control group and 64 (32.5%) patients in the rate-control group (hazard ratio 0.71 95% CI (0.49, 1.03), p=0.066). LVEF increased in the ablation-based group (10.1±1.2% vs 3.8±1.2%, p=0.017); six-minute walk distance improved (44.9±9.1 meters 27.5±9.7 meters, p=0.025) and NT-proBNP demonstrated a decrease (mean change -77.1% vs -39.2%, p<0.0001). MLHFQ demonstrated greater improvement in the ablation-based rhythm-control group (LSMD of -5.4, 95%CI (-10.5, -0.3), p=0.0036), as did the AFEQT score (LSMD of 6.2, 95%CI (1.7, 10.7), p=0.0005). Serious adverse events were observed in 50% of patients in both treatment groups. Conclusions: In patients with high burden AF and HF, there was no statistical difference in all-cause mortality or HF events with ablation-based rhythm-control versus rate-control, however, there was a non-significant trend for improved outcomes with ablation-based rhythm control over rate-control.

Atrial function in paroxysmal AF patients with and without heart failure with preserved ejection fraction: Data from the AF-RISK study

Atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF) are 2 cardiovascular conditions that often coexist. Strain phases of both the left and right atria are more impaired in paroxysmal AF patients with HFpEF than those without HFpEF in spite of comparable global longitudinal strain of the left ventricle. Atrial function may differentiate paroxysmal AF patients with HFpEF from those without HFpEF.

Atrial fibrillation in heart failure: Prime time for ablation!

Among heart failure (HF) patients, the onset of atrial fibrillation (AF) is often associated with a marked worsening of HF symptoms and increased morbidity and mortality. Among AF patients, 30%–40% experience at least 1 HF episode. New data suggest that, in HF patients, AF rhythm control is superior to rate control and that rhythm control by catheter ablation is superior to antiarrhythmic drugs. In recent years, several trials that addressed the impact of AF ablation on morbidity and mortality included HF patients; however, studies also have specifically investigated the growing cohort of patients suffering from both HF and AF. Although the majority of these trials showed a marked benefit of AF ablation, there are hints that not all HF patients benefit equally from AF ablation. AF treatment in HF is challenging because the same cardiac morbidities that lead to HF can also act as risk factors for the development of the arrhythmogenic substrate that causes AF. In many patients, this arrhythmogenic substrate can be successfully treated by antral pulmonary vein isolation pulmonary vein isolation (PVI). However, due to advanced atrial disease, some patients also might require multiple procedures and/or “PVI plus” ablation strategies. In this review, we summarize current data on the effect of AF ablation in HF patients, with a special focus on the beneficial effect of AF ablation in different clinical HF subgroups.

Metabolomic and Proteomic Analyses of Persistent Valvular Atrial Fibrillation and Non-Valvular Atrial Fibrillation

Atrial fibrillation (AF) is an abnormal heart rhythm related to an increased risk of heart failure, dementia, and stroke. The distinction between valvular and non-valvular AF remains a debate. In this study, proteomics and metabolomics were integrated to describe the dysregulated metabolites and proteins of AF patients relative to sinus rhythm (SR) patients. Totally 47 up-regulated and 41 down-regulated proteins in valvular AF, and 59 up-regulated and 149 down-regulated proteins in non-valvular AF were recognized in comparison to SR patients. Moreover, 58 up-regulated and 49 significantly down-regulated metabolites in valvular AF, and 47 up-regulated and 122 down-regulated metabolites in persistent non-valvular AF patients were identified in comparison to SR patients. Based on analysis of differential levels of metabolites and proteins, 15 up-regulated and 22 down-regulated proteins, and 13 up-regulated and 122 down-regulated metabolites in persistent non-valvular AF were identified relative to valvular AF. KEGG pathway enrichment analysis showed the altered proteins and metabolites were significantly related to multiple metabolic pathways, such as Glycolysis/Gluconeogenesis. Interestingly, the enrichment pathways related to non-valvular AF were obviously different from those in valvular AF. For example, valvular AF was significantly related to Glycolysis/Gluconeogenesis, but non-valvular AF was more related to Citrate cycle (TCA cycle). Correlation analysis between the differentially expressed proteins and metabolites was also performed. Several hub proteins with metabolites were identified in valvular AF and non-valvular AF. For example, Taurine, D-Threitol, L-Rhamnose, and DL-lactate played crucial roles in valvular AF, while Glycerol-3-phosphate dehydrogenase, Inorganic pyrophosphatase 2, Hydroxymethylglutaryl-CoAlyase, and Deoxyuridine 5-triphosphate nucleotidohydrolase were crucial in non-valvular AF. Then two hub networks were recognized as potential biomarkers, which can effectively distinguish valvular AF and non-valvular persistent AF from SR samples, with areas under curve of 0.75 and 0.707, respectively. Hence, these metabolites and proteins can be used as potential clinical molecular markers to discriminate two types of AF from SR samples. In summary, this study provides novel insights to understanding the mechanisms of AF progression and identifying novel biomarkers for prognosis of non-valvular AF and valvular AF by using metabolomics and proteomics analyses.

Atrial fibrillation and heart failure: A contemporary review of current management approaches

Atrial fibrillation (AF) and heart failure (HF) frequently coexist and complicate the course of treatment of each other. AF with rapid ventricular conduction can lead to tachycardia-mediated cardiomyopathy, which is a reversible cause of cardiomyopathy. However, in most cases, AF is the manifestation of various underlying cardiomyopathies. Guideline-directed pharmacological and device therapy for HF is essential. The management options for AF and HF include pharmacological rhythm control, pharmacological rate control, and interventional approaches, which include catheter ablation for AF via pulmonary vein isolation and atrioventricular node ablation. This is a contemporary review to discuss the available evidence regarding the various management approaches in this specific patient group.