Catheter Ablation of Atrial Fibrillation in Patients With Heart Failure

Association between weight loss and outcomes in patients undergoing atrial fibrillation ablation: a systematic review and dose-response meta-analysis

BACKGROUND

Obesity is an strong risk factor for atrial fibrillation (AF), and obesity can affect the prognosis of AF. However, the role of weight loss on outcomes after ablation remains unclear.

OBJECTIVES

This study aims to determine the relationship between weight loss and outcomes in patients with AF ablation, as well as the potential dose-response relationship.

METHODS

The Cochrane Library, PubMed, and Embase databases were searched to identify studies that reported a relationship between weight loss and ablation up to August 17, 2021. Relative risks (RRs) were pooled using random-effects models.

RESULTS

One randomized, open-labeled clinical trial and seven cohort studies involving 1283 patients were included. The mean body mass index of all included studies was over 30 kg/m2. The clinical trial showed a non-significant benefit of weight loss intervention on AF recurrence (Odd risk [OR] = 1.02, 95% confidence interval [CI] 0.70-1.47). Meta-analysis based on observational studies showed that the recurrence rate of AF after ablation was significantly reduced (RR = 0.43, 95% CI 0.22-0.81, I2 = 97%) in relatively obese patients with weight loss compared with the control group. Each 10% reduction in weight was associated with a decreased risk of AF recurrence after ablation (RR = 0.54, 95% CI 0.33-0.88) with high statistical heterogeneity (I2 = 76%). An inverse linear association (Pnon-linearity = 0.27) between AF relapse and increasing weight loss was found.

CONCLUSIONS

Our results first suggest an inverse dose-response association between weight loss and risk of recurrent AF after ablation, with moderate certainty.

Meta-analysis of the Usefulness of Catheter Ablation of Atrial Fibrillation in Patients With Heart Failure With Preserved Ejection Fraction

Catheter ablation improves clinical outcomes in atrial fibrillation (AF) patients with heart failure (HF) with reduced ejection fraction (HFrEF). However, the role of catheter ablation in HF with a preserved ejection fraction (HFpEF) is less clear. We performed a literature search and systematic review of studies that compared AF recurrence at one year after catheter ablation of AF in patients with HFpEF versus those with HFrEF. Risk ratio (RR; where a RR <1.0 favors the HFpEF group) and mean difference (MD; where MD <0 favors the HFpEF group) 95% confidence intervals (CI) were measured for dichotomous and continuous variables, respectively. Six studies with a total of 1,505 patients were included, of which 764 (51%) had HFpEF and 741 (49%) had HFrEF. Patients with HFpEF experienced similar recurrence of AF 1 year after ablation on or off antiarrhythmic drugs compared with those with HFrEF (RR 1.01; 95% CI 0.76, 1.35). Fluoroscopy time was significantly shorter in the HFpEF group (MD -5.42; 95% CI -8.51, -2.34), but there was no significant difference in procedure time (MD 1.74; 95% CI -11.89, 15.37) or periprocedural adverse events between groups (RR 0.84; 95% CI 0.54,1.32). There was no significant difference in hospitalizations between groups (MD 1.18; 95% CI 0.90, 1.55), but HFpEF patients experienced significantly less mortality (MD 0.41; 95% CI 0.18, 0.94). In conclusion, based on the results of this meta-analysis, catheter ablation of AF in patients with HFpEF appears as safe and efficacious in maintaining sinus rhythm as in those with HFrEF.

Comparison of Outcomes After Ablation of Atrial Fibrillation in Patients With Heart Failure With Preserved Versus Reduced Ejection Fraction

Catheter ablation improves outcomes in atrial fibrillation (AF) patients with heart failure (HF) with reduced ejection fraction (HFrEF). We sought to evaluate the efficacy and safety of catheter ablation of AF in HF patients with a preserved ejection fraction (HFpEF). We performed a retrospective study of all patients who underwent de novo radiofrequency catheter ablation enrolled in the UC San Diego AF Ablation Registry. The primary outcome was recurrence of all atrial arrhythmias on or off antiarrhythmic drugs (AAD). Of 547 total patients, 51 (9.3%) had HFpEF, 40 (7.3%) had HFrEF, and 456 (83.4%) were without HF. There was no difference in recurrence of atrial arrhythmias on or off AAD (Adjusted Hazard Ratio [AHR] 1.92 [95% CI 0.97 to 3.83] for HFpEF vs HFrEF and AHR 0.90 [95% CI 0.59 to 1.39] for HFpEF vs no HF) or off AAD (AHR 1.96 [95% CI 0.99 to 3.90] for HFpEF vs HFrEF and AHR 1.14 [95% CI 0.74 to 1.77] for HFpEF vs no HF). There was also no difference in rates of all-cause hospitalizations (AHR 1.80 [95% CI 0.97 to 3.33] for HFpEF vs HFrEF and AHR 2.05 [95% CI 1.30 to 3.23] for HFpEF vs no HF) or rates of all-cause mortality (AHR 0.53 [95% CI 0.05 to 6.11] for HFpEF vs HFrEF and AHR 2.46 [95% CI 0.34 to 17.92] for HFpEF vs no HF). There were no significant differences in AAD use (p = 0.176) or procedural complications between groups (p = 0.980). In conclusion, there were no significant differences in arrhythmia-free survival between patients with HFpEF and HFrEF that underwent catheter ablation of AF.

Atrial fibrillation in patients with heart failure with preserved ejection fraction

PURPOSE OF REVIEW

To review the shared pathology of atrial fibrillation and heart failure with preserved ejection fraction (HFpEF) and the prognostic, diagnostic, and treatment challenges incurred by the co-occurrence of these increasingly prevalent diseases.

RECENT FINDINGS

Multiple risk factors and mechanisms have been proposed as potentially linking atrial fibrillation and HFpEF, with systemic inflammation more recently being invoked. Nonvitamin K oral anticoagulants, left atrial appendage occlusion devices, and catheter ablation have emerged as alternative treatment options. Other novel pharmacological agents, such as neprilysin inhibitors, need to be studied further in this patient population.

SUMMARY

Atrial fibrillation and HFpEF commonly co-occur because of their shared risk factors and pathophysiology and incur increased morbidity and mortality relative to either condition alone. Although the presence of both diseases can often make each diagnosis difficult, it is important to do so early in the disease course as there are now a variety of treatment options aimed at improving symptoms and quality of life, slowing disease progression, and improving prognosis. However, more research needs to be performed on the role of catheter ablation in this population. Novel pharmacologic and procedural treatment options appear promising and may further improve the treatment options available to this growing population.

Reconstruction of right ventricular outflow tract stenosis and right ventricular failure after Ross procedure - comprehensive assessment of adult congenital heart disease with four-dimensional imaging: a case report

BACKGROUND

Re-intervention after Ross procedure into the right ventricular outflow tract might be needed in patients in the long term. However, right ventricular outflow tract re-intervention indications are still unclear. Comprehensive assessment of total hemodynamics is needed. A 42-year-old Japanese woman was referred to our hospital for moderately severe pulmonary regurgitation and severe tricuspid regurgitation after a Ross-Konno procedure. Thirteen years after surgery, she developed atrial fibrillation and atrial flutter and complained of dyspnea. Electrophysiological studies showed re-entry circuit around the low voltage area of the lateral wall on the right atrium. Four-dimensional flow magnetic resonance imaging revealed moderate pulmonary regurgitation, severe tricuspid regurgitation, and a dilated right ventricle. Flow energy loss in right ventricle calculated from four-dimensional flow magnetic resonance imaging was five times higher than in normal controls, suggesting an overload of the right-sided heart system. Her left ventricular ejection fraction was almost preserved. Moreover, the total left interventricular pressure difference, which shows diastolic function, revealed that her sucking force in left ventricle was preserved. After the comprehensive assessments, we performed right ventricular outflow tract reconstruction, tricuspid valve annuloplasty, and right-side Maze procedure. A permanent pacemaker with a single atrial lead was implanted 14 days postoperatively. She was discharged 27 days postoperatively. Echocardiography performed 3 months later showed that the size of the dilated right ventricle had significantly reduced.

DISCUSSION

A four-dimensional imaging tool can be useful in the decision of re-operation in patients with complex adult congenital heart disease. The optimal timing of surgery should be considered comprehensively.

Sex differences of resource utilisation and outcomes in patients with atrial arrhythmias and heart failure

Objective

Atrial fibrillation or atrial flutter (AF) and heart failure (HF) often go hand in hand and, in combination, lead to an increased risk of death compared with patients with just one of both entities. Sex-specific differences in patients with AF and HF are under-reported. Therefore, the aim of this study was to investigate sex-specific catheter ablation (CA) use and acute in-hospital outcomes in patients with AF and concomitant HF in a retrospective cohort study.

Methods

Using International Statistical Classification of Diseases and Related Health Problems and Operations and Procedures codes, administrative data of 75 hospitals from 2010 to 2018 were analysed to identify cases with AF and HF. Sex differences were compared for baseline characteristics, right and left atrial CA use, procedure-related adverse outcomes and in-hospital mortality.

Results

Of 54 645 analysed cases with AF and HF, 46.2% were women. Women were significantly older (75.4±9.5 vs 68.7±11.1 years, p<0.001), had different comorbidities (more frequently: cerebrovascular disease (2.4% vs 1.8%, p<0.001), dementia (5.3% vs 2.2%, p<0.001), rheumatic disease (2.1% vs 0.8%, p<0.001), diabetes with chronic complications (9.7% vs 9.1%, p=0.033), hemiplegia or paraplegia (1.7% vs 1.2%, p<0.001) and chronic kidney disease (43.7% vs 33.5%, p<0.001); less frequently: myocardial infarction (5.4% vs 10.5%, p<0.001), peripheral vascular disease (6.9% vs 11.3%, p<0.001), mild liver disease (2.0% vs 2.3%, p=0.003) or any malignancy (1.0% vs 1.3%, p<0.001), underwent less often CA (12.0% vs 20.7%, p<0.001), had longer hospitalisations (6.6±5.8 vs 5.2±5.2 days, p<0.001) and higher in-hospital mortality (1.6% vs 0.9%, p<0.001). However, in the multivariable generalised linear mixed model for in-hospital mortality, sex did not remain an independent predictor (OR 0.96, 95% CI 0.82 to 1.12, p=0.579) when adjusted for age and comorbidities. Vascular access complications requiring interventions (4.8% vs 4.2%, p=0.001) and cardiac tamponade (0.3% vs 0.1%, p<0.001) occurred more frequently in women, whereas stroke (0.6% vs 0.5%, p=0.179) and death (0.3% vs 0.1%, p=0.101) showed no sex difference in patients undergoing CA.

Conclusions

There are sex differences in patients with AF and HF with respect to demographics, resource utilisation and in-hospital outcomes. This needs to be considered when treating women with AF and HF, especially for a sufficient patient informed decision making in clinical practice.

Safety and efficacy of the ThermoCool SmartTouch SurroundFlow catheter for atrial fibrillation ablation: A meta-analysis

Background

The ThermoCool Smarttouch Surroundflow catheter (STSFc) is an advanced catheter, which integrating contact force sensing and surroundflow technology. However, comparative data between STSFc and contact force sensing catheter (Thermocool SmartTouch catheter [STc]) are limited.

Hypothesis

We thought that STSFc might bring more clinical benefits. The aim of this meta‐analysis was to compare the safety and efficiency between the STSFc and the STc for treatment of atrial fibrillation (AF).

Methods

The Medline, PubMed, Embase, and Cochrane Library databases were searched for studies comparing STSFc and STc.

Results

Four trials involving 727 patients were included in the study. Pool‐analyses demonstrated that, as compared STc ablation, STSFc ablation was more beneficial in terms of procedural times (standard mean difference [SMD]: −0.22; 95% confidence interval [CI], −0.37 to −0.07, P = .005) and irrigation fluid volume (SMD: −1.94; 95% CI, −2.65 to −1.22, P < .0001). There was no significant difference between STSFc and STc (risk ratio [RR]: 1.02; 95% CI: 0.86 to 1.21, P = .79) for free from AF. Evidence of complications were low and similar for both groups (RR: 0.83; 95% CI: 0.19‐3.55, P = .80). Additionally, patients administered STSFc ablation tended to have shorter fluoroscopic times (SMD: −0.20; 95% CI, −0.63‐0.23, P = .21).

Conclusions

STSFc ablation was associated with reducing procedural times and irrigation fluid volume. Further, STSFc ablation tended to shorten fluoroscopic times. Therefore, STSFc ablation would be a better choice for AF patients especially in patients with heart failure.