Efficacy and feasibility of cryoballoon ablation for atrial fibrillation in patients with heart failure: A large-scale multicenter study

INTRODUCTION

Data are limited regarding outcomes of cryoballoon ablation for atrial fibrillation (AF) in patients with heart failure (HF). This large-scale multicenter study aimed to evaluate the prognosis of patients with HF after cryoballoon ablation for AF.

METHODS

Among 3655 patients undergoing cryoballoon ablation at 17 institutions, 549 patients (15%) (391 with paroxysmal AF and 158 with persistent AF) diagnosed with HF preoperatively were analyzed. Clinical endpoints were recurrence, mortality, and HF hospitalization after ablation.

RESULTS

Most patients had a preserved left ventricular ejection fraction (LVEF) ≥ 50%. During a mean follow-up period of 25.7 months, recurrence, all-cause death, and HF hospitalization occurred in 29%, 4.0%, and 4.8%, respectively. Cardiac function on echocardiography and B-type natriuretic peptide (BNP) levels significantly improved postoperatively, and the effect was more pronounced in the nonrecurrence group. Major complications occurred in 33 patients (6.0%), but most complications were phrenic nerve palsy (3.6%). Although death and HF hospitalization occurred more frequently in patients with LVEF ≤ 40% (n = 73) and New York Heart Association (NYHA) class III-IV (n = 19) than other subgroups, the BNP levels, and LVEF significantly improved after ablation in all LVEF and NYHA class subgroups. High BNP levels, NHYA class, CHADS₂ score, and structural heart disease, but not postablation recurrence, independently predicted death, and HF hospitalization on multivariate analysis. The patients with tachycardia-induced cardiomyopathy had better recovery of BNP levels and LVEF after ablation than those with structural heart disease.

CONCLUSIONS

Cryoballoon ablation for AF in HF patients is feasible and leads to significantly improved cardiac function.

Molecular Signatures of Human Chronic Atrial Fibrillation in Primary Mitral Regurgitation

Objectives

Transcriptomics of atrial fibrillation (AFib) in the setting of chronic primary mitral regurgitation (MR) remains to be characterized. We aimed to compare the gene expression profiles of patients with degenerative MR in AFib and sinus rhythm (SR) for a clearer picture of AFib pathophysiology.

Methods

After transcriptomic analysis and bioinformatics (n = 59), differentially expressed genes were defined using 1.5-fold change as the threshold. Additionally, independent datasets from GEO were included as meta-analyses.

Results

QRT-PCR analysis confirmed that AFib persistence was associated with increased expression molecular changes underlying a transition to heart failure (NPPB, P = 0.002; ANGPTL2, P = 0.002; IGFBP2, P = 0.010), structural remodeling including changes in the extracellular matrix and cellular stress response (COLQ, P = 0.003; COMP, P = 0.028; DHRS9, P = 0.038; CHGB, P = 0.038), and cellular stress response (DNAJA4, P = 0.038). Furthermore, AFib persistence was associated with decreased expression of the targets of structural remodeling (BMP7, P = 0.021) and electrical remodeling (CACNB2, P = 0.035; MCOLN3, P = 0.035) in both left and right atrial samples. The transmission electron microscopic analysis confirmed ultrastructural atrial remodeling and autophagy in human AFib atrial samples.

Conclusions

Atrial cardiomyocyte remodeling in persistent AFib is closely linked to alterations in gene expression profiles compared to SR in patients with primary MR. Study findings may lead to novel therapeutic targets. This trial is registered with ClinicalTrials.gov identifier: NCT00970034.

Atrial fibrillation ablation in heart failure: What do we know? What can we do?

Atrial fibrillation (AF) and heart failure with reduced ejection fraction (HFrEF) are two conditions that frequently impact reciprocally on each other. Patients with HFrEF have an increased risk of stroke, hospitalization and mortality after they develop AF and vice versa, AF causing deterioration of the ejection fraction is also associated to increased mortality. Catheter ablation has emerged as an effective alternative to antiarrhythmic drug treatment to maintain sinus rhythm and some randomized trials have shown a potential benefit in terms of mortality and hospitalization. This review discusses the available evidence regarding catheter ablation treatment in this specific patient group.

Usefulness of Post-Procedural Plasma Brain Natriuretic Peptide Levels to Predict Recurrence After Catheter Ablation of Atrial Fibrillation in Patients With Left Ventricular Systolic Dysfunction

Catheter ablation (CA) of atrial fibrillation (AF) improves cardiac function, resulting in a decrease in plasma brain natriuretic peptide (BNP) levels in patients with reduced left ventricular ejection fraction (LVEF). This study sought to examine the pre-procedural and post-procedural correlations between BNP levels and cardiac function and the associations between the BNP levels and recurrence after CA in patients with AF and reduced LVEF. Of 3142 consecutive patients who underwent first-time CA of AF at our institute, a total of 217 patients with LVEF <50% were enrolled. Significant decrease in BNP levels (from a median of 198 [interquartile range 113 to 355] to 47.7 [22.7 to 135] pg/ml, p <0.001) and improvement in LVEF (from 39±9% to 61±16%, p <0.001) were observed 3 months after CA. There was a linear correlation between log-transformed BNP levels and cardiac measures (LVEF: r = -0.64; LV end-diastolic volume: r = 0.25; LV end-systolic volume: r = 0.43; left atrial volume: r = 0.52; all p <0.001). During a median follow-up of 35 months, AF recurrence after a 3-month blanking period was observed in 80 patients (37%). Cox proportional hazard regression analysis after adjustment for cardiac measures significant in univariate analysis revealed that early recurrence within the blanking period (hazard ratio, 4.88; 95% confidence interval, 2.89 to 8.25) and elevated post-procedural BNP levels (2.02 per unit log increase; 1.14 to 3.56) were significant predictors of AF recurrence, but pre-procedural BNP was not. In conclusion, post-procedural BNP levels at the end of the blanking period predicted subsequent AF recurrence in patients with reduced LVEF, independent of early recurrence.

Association between reactive hyperemia peripheral arterial tonometry index and atrial fibrillation recurrence after catheter ablation

Background

Vascular endothelial function has recently been recognized as an independent predictor of cardiovascular events. However, studies investigating its association with atrial fibrillation (AF) are lacking. This study aimed to examine association with AF recurrence and vascular endothelial function as assessed using natural logarithmic transformation of reactive hyperemia peripheral arterial tonometry index (LnRHI).

Methods

Ninety-nine consecutive AF patients who underwent catheter ablation (CA) at Shinshu University Hospital between September 2015 and April 2017 were enrolled. LnRHI was measured 48 to 72 h before CA using the EndoPAT system. The primary outcome was AF recurrence beyond 3 months post-ablation.

Results

A total of 30 (30.3%) patients experienced AF recurrence after CA over a median follow-up period of 210 days (range: 93–764 days). Female sex and low LnRHI were significantly associated with AF recurrence. In multivariate analysis, LnRHI was an independent predictor of AF recurrence (hazard ratio: 0.087, 95% confidence interval 0.015–0.51, p = 0.007). In comparison in Kaplan-Meier analysis of high LnRHI (LnRHI ≥0.52, n = 52) and low LnRHI (LnRHI ≪0.52, n = 47) groups, AF recurrence rate was significantly higher in the low LnRHI group (log-rank test, p = 0.043). A negative correlation was observed between LnRHI and AF duration, whereby LnRHI was significantly decreased when the duration of AF events exceeded 1 year.

Conclusion

Decreased LnRHI was associated with AF recurrence after CA and prolonged AF duration.

Catheter Ablation of Atrial Fibrillation in Patients With Heart Failure

Atrial fibrillation (AF) and heart failure (HF) both have become major cardiovascular epidemics, adversely affecting quality of life, decreasing longevity, and imparting a large economic burden on the healthcare system. Both share similar risk factors and frequently coexist, leading to increased morbidity and mortality relative to patients with either condition alone. Although evidence-based treatment guidelines for both diseases exist, consensus treatment strategies are less clear when AF and HF co-occur. Given the risks of antiarrhythmic drugs and their incomplete success in maintaining sinus rhythm, catheter ablation has become an increasingly popular alternative to pharmacologic rhythm control in symptomatic patients with AF with normal cardiac function. Although multiple studies have demonstrated the efficacy of catheter ablation in AF, studies examining the use of catheter ablation specifically in patients with HF have recently begun to emerge and provide some guidance in this group of patients. In this review, we examine the effects of catheter ablation of AF in patients with HF on maintenance of sinus rhythm, left ventricular ejection fraction, exercise capacity, quality of life, hospitalization, and mortality rates. Data regarding both HF with reduced ejection fraction and preserved ejection fraction are discussed.

Ablation for Atrial Fibrillation in Heart Failure with Reduced Ejection Fraction

AF and heart failure with reduced ejection fraction (HFrEF) frequently coexist. Catheter ablation is an increasingly utilised treatment strategy for patients with AF and can be safely performed and is effective in achieving sinus rhythm for patients with HFrEF. Successful ablation may result in improved LV function, clinical heart failure status, quality of life and possibly even mortality. This review summarises the literature analysing efficacy, safety and outcomes of AF ablation for patients with HFrEF.

Treatment of Patients With Atrial Fibrillation and Heart Failure With Reduced Ejection Fraction

Atrial fibrillation (AF) and heart failure with reduced ejection fraction (HFrEF) frequently coexist, and each complicates the course and treatment of the other. Recent population-based studies have demonstrated that the 2 conditions together increase the risk of stroke, heart failure hospitalization, and all-cause mortality, especially soon after the clinical onset of AF. Guideline-directed pharmacological therapy for HFrEF is important; however, although there are various treatment modalities for AF, there is no clear consensus on how best to treat AF with concomitant HFrEF. This in-depth review discusses the available data for the treatment of AF in the setting of HFrEF, focuses on areas where more investigation is necessary, examines the clinical implications of randomized and observational clinical trials, and presents suggestions for individualized treatment strategies for specific patient groups.

Common variants predict recurrence after nonfamilial atrial fibrillation ablation in Chinese Han population

BACKGROUND

Genome-wide association studies (GWAS) have identified several loci associated with atrial fibrillation (AF) and have been reportedly associated with response to catheter ablation for AF in patients of European ancestry; however, associations between susceptibility loci and clinical recurrence of AF after catheter ablation have not been examined in Chinese Han populations. To the personalization of catheter ablation for AF, we examined whether these single nucleotide polymorphisms (SNPs) can predict clinical outcomes after catheter ablation for AF in Chinese Han population.

METHODS AND RESULTS

The association between 8 SNPs and AF was studied in 1418 AF patients and 1424 controls by the unconditional logistic regression analysis. The survival analyses were used to compare AT/AF recurrence differences among 438 AF patients, which were classified by the genotype of rs2200733. rs2200733 and rs6590357 were significantly associated with AF in Chinese Han population. In addition, rs2200733 was associated with clinical recurrence of AF after catheter ablation. In Kaplan-Meier survival analysis, the recurrence-free rates for AF with TT and with TC+CC were 35.5% and 61.9%, respectively (P=0.0009). In multivariate Cox regression analysis, rs2200733 was strong independent risk factor for recurrence.

CONCLUSION

rs2200733 risk allele at the 4q25 predicted impaired clinical response to catheter ablation for AF in Chinese Han population. Our findings suggested rs2200733 polymorphism may be used as a clinical tool for selection of patients for AF catheter ablation.