Catheter Ablation: First-Line Therapy for Atrial Fibrillation in Systolic Heart Failure?

First-line therapy: insights from a real-world analysis of cryoablation in patients with atrial fibrillation

AIMS

Pulmonary vein isolation (PVI) using cryoballoon ablation (CBA) is mainly reserved for patients with drug-refractory or drug-intolerant symptomatic atrial fibrillation. We evaluated a large cohort of patients treated in a real-world setting and examined the safety and efficacy profile of CBA when applied as a first-line treatment for atrial fibrillation.

METHODS

In total, 249 patients (23% women; 56 ± 13 years; mean left atrial diameter 41 ± 7 mm; 73.5% paroxysmal atrial fibrillation; and 26.5% persistent atrial fibrillation) underwent an index PVI by CBA. Data were collected prospectively in the framework of the 1STOP ClinicalService project, involving 26 Italian cardiology centers.

RESULTS

Median procedure and fluoroscopy times were 90.0 and 21.0 min, respectively. Acute procedural success was 99.8%. Acute/periprocedural complications were observed in seven patients (2.8%), including: four transient diaphragmatic paralyses, one pericardial effusion (not requiring any intervention), one transient ischemic attack, and one minor vascular complication. The Kaplan--Meier freedom from atrial fibrillation recurrence was 86.3% at 12 months and 76% at 24 months. Seventeen patients (6.8%) had a repeat catheter ablation procedure during the follow-up period. At last follow-up, 10% of patients were on an anticoagulation therapy, whereas 6.8% were on an antiarrhythmic drug.

CONCLUSION

In our multicenter real-world experience, PVI by CBA in a first-line atrial fibrillation patient population was well tolerated, effective, and promising. CBA with a PVI strategy can be used to treat patients with paroxysmal and persistent atrial fibrillation with good acute procedural success, short procedure times, and acceptable safety.

CLINICAL TRIAL REGISTRATION

clinicaltrials.gov (NCT01007474).

Meta-Analysis of Catheter Ablation versus Medical Therapy in Patients with Atrial Fibrillation Without Heart Failure

Introduction

Catheter ablation has shown to reduce mortality in patient with atrial fibrillation (AF) and heart failure (HF) with reduced ejection fraction. Its effect on mortality in patients without HF has not been well elucidated.

Methods

Thirteen randomized controlled trials encompassing 3856 patients were selected using PubMed, Embase and the CENTRAL till April 2019. Estimates were reported as random effects risk ratio (RR) with 95% confidence intervals (CI).

Results

Compared with medical therapy, catheter ablation did not reduce the risk of all-cause mortality (RR, 0.86, 95% CI, 0.62-1.19, P=0.36; I2=0), stroke (RR, 0.55, 95% CI, 0.18-1.66, P=0.29; I2=0), need for cardioversion (RR, 0.84, 95% CI, 0.66-1.08, P=0.17; I2=0) or pacemaker (RR, 0.59, 95% CI, 0.34-1.01, P=0.06; I2=0). However, ablation reduced the RR of cardiac hospitalization (0.37, 95% CI, 0.18-0.77, P=0.01; I2=86), and recurrent atrial arrhythmia (0.46, 95% CI, 0.35-0.60, P<0.001; I2=87). There were non-significant differences among treatment groups with respect to major bleeding (RR, 1.89, 95% CI, 0.59-6.08, P=0.29; I2=15), and pulmonary vein stenosis (RR, 3.00, 95% CI, 0.83-10.87, P=0.09; I2=0), but had significantly higher rates of pericardial tamponade (RR, 4.46, 95 % CI, 1.70-11.72, P<0.001; I2=0).

Conclusions

Catheter ablation did not improve survival compared with medical therapy in patients with AF without HF. Catheter ablation reduced cardiac hospitalization and recurrent atrial arrhythmia at the expense of pericardial tamponade.

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.