Catheter Ablation of Atrial Fibrillation in Patients With Heart Failure and Preserved Ejection Fraction

Comparing outcomes after pulmonary vein isolation in patients with systolic and diastolic heart failure

Background

The benefit of pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF) and heart failure with reduced ejection fraction (HFrEF) is well established; its efficacy in patients with heart failure preserved ejection fraction (HFpEF) is less clear.

Objective

The objective of the study was to compare AF and heart failure (HF) rehospitalizations after PVI in patients with HFpEF vs HFrEF.

Methods

The IBM MarketScan Database was used to identify patients undergoing PVI for AF. Patients were categorized by HF status: absence of HF, presence of HFrEF, or presence of HFpEF. Primary outcomes were HF and arrhythmia hospitalizations after PVI.

Results

A total of 32,524 patients were analyzed: 27,900 with no HF (86%), 2948 with HFrEF (9%), and 1676 with HFpEF (5%). Compared with those with no HF, both patients with HFrEF and HFpEF were more likely to be hospitalized for HF (hazard ratio [HR] 7.27; P < .01 for HFrEF and HR 9.46; P < .01 for HFpEF) and for AF (HR 1.17; P < .01 for HFrEF and HR 1.74; P < .01 for HFpEF) after PVI. In matched analysis, 23% of patients with HFrEF and 24% patients with HFpEF demonstrated a reduction in HF hospitalizations (P = .31) and approximately one-third demonstrated decreased arrhythmia rehospitalizations (P = .57) in the 6 months after PVI. Compared with those with HFrEF in longer-term follow-up (>1 year), patients with HFpEF were more likely to have HF (HR 1.30; P < .01) and arrhythmia (HR 1.19; P < .01) rehospitalizations.

Conclusion

Reductions in HF and arrhythmia hospitalizations are observed early after PVI across all patients with HF, but patients with HFpEF demonstrate higher HF rehospitalization and arrhythmia recurrence in longer-term follow-up than do patients with HFrEF.

Efficacy and safety of catheter ablation for atrial fibrillation in patients with heart failure with preserved ejection fraction: a systematic review and meta-analysis

Background

Catheter ablation (CA) effectively treats atrial fibrillation (AF) in heart failure (HF) with reduced ejection fraction (HFrEF), improving clinical outcomes. However, its benefits for AF patients with heart failure with preserved ejection fraction (HFpEF) are still unclear.

Methods

We systematically searched PubMed, Embase, Web of Science, the Cochrane Library, and Scopus for studies investigating outcomes of CA in AF patients with HFpEF. Efficacy indicators included freedom from AF and antiarrhythmic drugs (AAD) free AF elimination. Safety indicators comprised total complications, HF admission, all-cause admission, and all-cause mortality. Sixteen studies with 20,796 patients included in our research.

Results

The comprehensive analysis demonstrated that, when comparing CA with medical therapy in HFpEF, no significant differences were observed in terms of HF admissions, all-cause admissions, and all-cause mortality [(OR: 0.42; 95% CI: 0.12-1.51, P = 0.19), (HR: 0.78; 95% CI: 0.48-1.27, P = 0.31), and (OR: 1.10; 95% CI: 0.83-1.44, P = 0.51)], while freedom from AF was significantly higher in CA (OR: 5.88; 95% CI: 2.99-11.54, P < 0.00001). Compared with HFrEF, CA in HFpEF showed similar rates of freedom from AF, AAD-free AF elimination, total complications, and all-cause admission were similar [(OR:0.91; 95% CI: 0.71,1.17, P =0.47), (OR: 0.97; 95% CI: 0.50-1.86, P = 0.93), (OR: 1.27; 95% CI: 0.47-3.41, P = 0.64), (OR: 1.11; 95% CI: 0.72, 1.73; P = 0.63)]. However, CA in HFpEF was associated with lower rates of HF admission and all-cause mortality [(OR: 0.35; 95% CI: 0.20, 0.60; P = 0.0002), (OR: 0.40; 95% CI: 0.18, 0.85; P = 0.02)]. Compared with patients without HF, CA in HFpEF patients exhibited lower rates of AAD-free AF elimination (OR: 0.48; 95% CI: 0.30, 0.75; P = 0.001). However, their rates of freedom from AF and total complications were similar [(OR: 0.70; 95% CI: 0.48, 1.02; P = 0.06), (OR: 0.60; 95% CI: 0.19, 1.90; P = 0.38)].

Conclusion

This meta-analysis conducted provided a comprehensive evaluation of the efficacy and safety of CA in patients with AF and HFpEF. The results suggest that CA may represent a valuable treatment strategy for patients with AF and HFpEF.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/#recordDetails, identifier (CRD42024514169).

Functional Mitral Regurgitation and Heart Failure With Preserved Ejection Fraction: Clinical Implications and Management

Heart failure with preserved ejection fraction (HFpEF) is highly prevalent and associated with worse cardiovascular outcomes. The pathophysiology of HFpEF mostly relies on the development of elevated left ventricle filling pressure, diastolic dysfunction, and atrial dilatation and impairment. This dynamic process may eventually lead to the development of functional mitral regurgitation (MR), characterized by mitral annular dilatation and consequent leaflet remodeling, in the context of preserved left ventricular ejection fraction. These observations highlight the possible common pathophysiology of MR and HFpEF. However, less is known about the prevalence and the clinical value of MR in the context of HFpEF. This review aims to provide an overview of the association and interplay between functional MR and HFpEF, discuss the underlying mechanisms that are common to these diseases, and summarize potential targeted pharmacological treatments.

[Cluster Analysis and Ablation Success Rate in Atrial Fibrillation Patients Undergoing Catheter Ablation]

Objective

Atrial fibrillation (AF) is a disease of high heterogeneity, and the association between AF phenotypes and the outcome of different catheter ablation strategies remains unclear. Conventional classification of AF (e.g. according to duration, atrial size, and thromboembolism risk) fails to provide reference for the optimal stratification of the prognostic risks or to guide individualized treatment plan. In recent years, research on machine learning has found that cluster analysis, an unsupervised data-driven approach, can uncover the intrinsic structure of data and identify clusters of patients with pathophysiological similarity. It has been demonstrated that cluster analysis helps improve the characterization of AF phenotypes and provide valuable prognostic information. In our cohort of AF inpatients undergoing radiofrequency catheter ablation, we used unsupervised cluster analysis to identify patient subgroups, to compare them with previous studies, and to evaluate their association with different suitable ablation patterns and outcomes.

Methods

The participants were AF patients undergoing radiofrequency catheter ablation at West China Hospital between October 2015 and December 2017. All participants were aged 18 years or older. They underwent radiofrequency catheter ablation during their hospitalization. They completed the follow-up process under explicit informed consent. Patients with AF of a reversible cause, severe mitral stenosis or prosthetic heart valve, congenital heart disease, new-onset acute coronary syndrome within three months prior to the surgery, or a life expectancy less than 12 months were excluded according to the exclusion criteria. The cohort consisted of 1102 participants with paroxysmal or persistent/long-standing persistent AF. Data on 59 variables representing demographics, AF type, comorbidities, therapeutic history, vital signs, electrocardiographic and echocardiographic findings, and laboratory findings were collected. Overall, data for the variables were rarely missing (<5%), and multiple imputation was used for correction of missing data. Follow-up surveys were conducted through outpatient clinic visits or by telephone. Patients were scheduled for follow-up with 12-lead resting electrocardiography and 24-hours Holter monitoring at 3 months and 6 months after the ablation procedure. Early ablation success was defined as the absence of documented AF, atrial flutter, or atrial tachycardia >30 seconds at 6-month follow-up. Hierarchical clustering was performed on the 59 baseline variables. All characteristic variables were standardized to have a mean of zero and a standard deviation of one. Initially, each patient was regarded as a separate cluster, and the distance between these clusters was calculated. Then, the Ward minimum variance method of clustering was used to merge the pair of clusters with the minimum total variance. This process continued until all patients formed one whole cluster. The "NbClust" package in R software, capable of calculating various statistical indices, including pseudo t2 index, cubic clustering criterion, silhouette index etc, was applied to determine the optimal number of clusters. The most frequently chosen number of clusters by these indices was selected. A heatmap was generated to illustrate the clinical features of clusters, while a tree diagram was used to depict the clustering process and the heterogeneity among clusters. Ablation strategies were compared within each cluster regarding ablation efficacy.

Results

Five statistically driven clusters were identified: 1) the younger age cluster (n=404), characterized by the lowest prevalence of cardiovascular and cerebrovascular comorbidities but the highest prevalence of obstructive sleep apnea syndrome (14.4%); 2) a cluster of elderly adults with chronic diseases (n=438), the largest cluster, showing relatively higher rates of hypertension, diabetes, stroke, and chronic obstructive pulmonary disease; 3) a cluster with high prevalence of sinus node dysfunction (n=160), with patients showing the highest prevalence of sick sinus syndrome and pacemaker implantation; 4) the heart failure cluster (n=80), with the highest prevalence of heart failure (58.8%) and persistent/long-standing persistent AF (73.7%); 5) prior coronary artery revascularization cluster (n=20), with patients of the most advanced age (median: 69.0 years old) and predominantly male patients, all of whom had prior myocardial infarction and coronary artery revascularization. Patients in cluster 2 achieved higher early ablation success with pulmonary veins isolation alone compared to extensive ablation strategies (79.6% vs. 66.5%; odds ratio [OR]=1.97, 95% confidence interval [CI]: 1.28-3.03). Although extensive ablation strategies had a slightly higher success rate in the heart failure group, the difference was not statistically significant.

Conclusions

This study provided a unique classification of AF patients undergoing catheter ablation by cluster analysis. Age, chronic disease, sinus node dysfunction, heart failure and history of coronary artery revascularization contributed to the formation of the five clinically relevant subtypes. These subtypes showed differences in ablation success rates, highlighting the potential of cluster analysis in guiding individualized risk stratification and treatment decisions for AF patients.

Implications of Atrial Fibrillation for Guideline-Directed Therapy in Patients With Heart Failure: JACC State-of-the-Art Review

Atrial fibrillation (AF) and heart failure (HF) are common cardiovascular conditions that frequently coexist. Among patients with HF, more than one-half also have AF. Both are associated with significant morbidity and mortality. Moreover, the prevalence of each is increasing globally, and this trend is expected to continue owing to an aging population and increased life expectancy. Diagnosis of AF in a patient with HF is associated with greater symptom burden, more frequent hospitalizations, and a worse prognosis. Guideline-directed medical therapy (GDMT) for HF can affect the incidence of AF. Once present, AF can influence the efficacy of some components of GDMT for HF. In this review, we discuss the effect of GDMT for HF across the spectrum of ejection fraction on prevention of AF as well as the benefit of GDMT in patients with vs without AF.

Heart failure and atrial fibrillation: Is atrial fibrillation ablation in heart failure pointless or mandatory?

A vast amount of now well-established clinical and epidemiological data indicates a close, interdependent, and symbiotic association between atrial fibrillation (AF) and heart failure (HF). Both AF and HF, when co-exist in a patient, have serious treatment and prognostic implications. Based on the prevailing knowledge of the topic, various societies have issued a number of guidelines regarding the management of patients with AF and HF. Overall, it is the rhythm control strategy that has shown beneficial effect over the rate control strategy with improvement in symptoms of AF and HF. While antiarrhythmic drugs (AADs) and catheter ablation (CA) may be utilized as rhythm control strategy for AF, both AADs and CA have limitations of their own. Furthermore, with the progress made in various pharmacotherapeutic agents in HF, one could question the utility of CA in HF (i.e., whether ablation is mandatory or pointless in patients who have HF). The purpose of this review is to discuss this very point, focusing on the beneficial, neutral, or detrimental outcome of CA based on the category and class of HF.

Prolonged PR intervals are associated with epicardial adipose tissue and recurrence after catheter ablation in persistent atrial fibrillation

Epicardial adipose tissue (EAT) has been reported to promote myocardial fibrosis and to affect intracardiac conduction. The PR interval reflects the conduction from the atria to the Purkinje fibers and may be associated with the EAT volume, especially in persistent atrial fibrillation (AF) patients. We aimed to investigate the relationship between the EAT and PR interval in patients with persistent AF. We enrolled 268 persistent AF patients who underwent catheter ablation (CA) and divided the patients into two groups: the normal PR interval group (PR interval less than 200 ms: Group N) and long PR interval group (PR interval 200 ms or more: Group L). We then analyzed the association between the total EAT volume around the heart and PR interval and calculated the ratio of the duration of the P wave (PWD) to the PR interval (PWD/PR interval). Moreover, we investigated whether a long PR interval was associated with the outcomes after ablation. The total EAT volume was significantly larger in Group L than Group N (Group N: 131.4 ± 51.8 ml vs. Group L: 151.3 ± 63.3 ml, p = 0.039). A positive correlation was also observed between the PWD/PR interval and EAT volume in Group L (r = 0.345, p = 0.039). A multivariate analysis also revealed that a long PR interval was independently associated with AF recurrence after CA (hazard ratio [HR] 2.071, p = 0.032). The total EAT volume was associated with a long PR interval, and a long PR interval was a significant risk factor for recurrence after ablation in persistent AF patients.

Heart failure with preserved ejection fraction and atrial fibrillation: clinical management in the context of recent therapeutic advances in heart failure and electrophysiology

Heart failure with preserved ejection fraction (HFpEF) and atrial fibrillation (AF) have emerged as major age-related epidemics within cardiology. Both conditions carry overlapping symptomatology, and delineating between AF and HFpEF from a diagnostic standpoint is challenging as echocardiographic and biomarker assessments used to diagnose HFpEF may be impacted by AF. Indeed, these two conditions are commonly found in the same individual, so much so that AF has been used in proposed diagnostic criteria for HFpEF. The frequent concomitant presence of these two conditions is associated with poorer quality of life, exertional capacity, as well as increased risk for decompensated heart failure and all-cause mortality. Though these deleterious effects of AF in HFpEF patients are well described, we currently have only a superficial understanding of the complex interplay between these two conditions. Preliminary studies on intervening in AF in HFpEF are very small, with mixed data on whether modifying the natural history of AF can lead to improvement in heart failure (HF) outcomes in HFpEF. In this review, we will describe the clinical implications of carrying both cardiovascular conditions, address recent advances in HFpEF and AF, and highlight preliminary studies targeted at reduction of effects associated with AF burden in HFpEF.

Adverse Events Requiring Hospitalization Following Catheter Ablation for Atrial Fibrillation in Heart Failure with versus without Systolic Dysfunction

BACKGROUND

The safety and efficacy of atrial fibrillation (AF) ablation in individuals with heart failure (HF) with preserved ejection fraction (EF), particularly concerning the occurrence of post-procedural adverse events necessitating hospitalization, including anticoagulant-associated major bleeding, still lack conclusive determination.

METHODS

Data from patients with HF and AF who underwent catheter ablation for AF between 2019 and 2022 at our institution were retrospectively reviewed. All participants were divided into an EF < 50% group or an EF ≥ 50% group according to their baseline left ventricular EF. The composite incidence of the clinical events following catheter ablation was compared between the two groups: (1) all-cause death, (2) HF hospitalization, (3) stroke or systemic embolism, and (4) major bleeding.

RESULTS

A total of 122 patients (75 years old, 68 male) were included. Of them, 62 (50.8%) patients had an EF ≥ 50%. EF ≥ 50% was an independent predictor of the composite endpoint (adjusted odds ratio 6.07, 95% confidence interval 1.37-26.99, p = 0.018). The incidences of each adverse event were not significantly different between the two groups, except for a higher incidence of major bleeding in the EF ≥ 50% group (12.7% vs. 0%, p = 0.026).

CONCLUSIONS

Among patients with HF coupled with AF, the incidence of adverse events following AF ablation proved notably elevated in patients with EF ≥ 50% in contrast to their counterparts with EF < 50%. This disparity primarily stems from a heightened occurrence of major bleeding within the EF ≥ 50% cohort. The strategy to reduce adverse events, especially in patients with EF ≥ 50%, remains the next concern.

Interventional Management of Atrial Fibrillation in the Chronic Heart Failure Population

Atrial fibrillation (AF) and heart failure (HF) synergistically interact to exacerbate each other. However, treatment of one entity can greatly improve management of the other. Although historically, permissive medical therapy was the mainstay of AF management in the HF population, recent data strongly favor early, often invasive, intervention for AF to reduce hard HF outcomes. It seems that intervening earlier in the time course of AF, though still not excluding persistent AF from treatment, may have more pronounced effects.

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.