Effect of catheter ablation on clinical outcomes in patients with atrial fibrillation and significant functional mitral regurgitation

Catheter ablation for atrial fibrillation in patients with significant mitral regurgitation: A systematic review and meta-analysis

BACKGROUND

Atrial fibrillation (AF) is commonly associated with cardiac structural abnormalities including mitral regurgitation (MR). Contemporary guidelines recommend consideration of early rhythm control strategies including catheter ablation (CA) for AF. However, the long-term efficacy of CA is highly variable across studies and patient populations, and the effect of coexisting MR on AF recurrence remains unclear.

OBJECTIVE

A systematic review and meta-analysis was performed to determine the impact of significant MR (defined as ≥moderate) on AF recurrence rate after CA and whether CA for AF is associated with significant changes in the severity of MR.

METHODS

A systematic search of PubMed, Embase, Web of Science, and Cochrane databases for all English-language studies published to December 31, 2023, was performed.

RESULTS

A total of 17 studies (N = 2624 patients) were retained for meta-analysis. The pooled recurrence proportion of AF after CA in patients with baseline significant MR was 36% (95% CI, 27%-46%) compared with 27% (14%-41%) in patients without. The pooled hazard ratio (95% CI) for AF recurrence after CA in the presence of significant MR was 2.47 (1.52-4.01; P < .001; Egger test P value, .0583). The pooled proportion of patients who witnessed MR improvement to nonsignificant (ie,

CONCLUSION

Baseline significant MR was independently predictive of AF recurrence rate after CA. Despite the increased AF recurrence rates after CA associated with significant MR, CA with maintenance of sinus rhythm appeared to improve the severity of MR, suggesting a possible induction of reverse positive atrial and mitral valvular remodeling.

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Key Words

• Atrial fibrillation
• Catheter ablation
• Mitral regurgitation
• Pulmonary vein isolation
• Review

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MESH Headings

• Atrial Fibrillation/surgery
• Atrial Fibrillation/physiopathology
• Atrial Fibrillation/complications
• Humans
• Mitral Valve Insufficiency/surgery
• Mitral Valve Insufficiency/physiopathology
• Mitral Valve Insufficiency/diagnosis
• Mitral Valve Insufficiency/complications
• Mitral Valve Insufficiency/etiology
• Catheter Ablation/methods
• Recurrence

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Affiliation(s)

Ross A Okazaki Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
Lillian C Flashner Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
Scott Kinlay Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts; Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts; Department of Medicine, Harvard Medical School, Boston, Massachusetts; Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
Adelqui O Peralta Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts; Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts; Department of Medicine, Harvard Medical School, Boston, Massachusetts
Peter S Hoffmeister Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts; Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts; Department of Medicine, Harvard Medical School, Boston, Massachusetts
Hirad Yarmohammadi Department of Medicine, Columbia University, New York, New York
Jacob Joseph Department of Medicine, Brown University, Providence, Rhode Island; Department of Medicine, VA Providence Healthcare System, Providence, Rhode Island
Matthew F Yuyun Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts; Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts; Department of Medicine, Harvard Medical School, Boston, Massachusetts.

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Efficacy of catheter ablation for atrial fibrillation in patients with significant functional mitral regurgitation

BACKGROUND

Catheter ablation has been established to be an effective therapy for paroxysmal atrial fibrillation (AF) and is recommended as the treatment of choice for many patients, including those with clinically significant functional mitral regurgitation (MR). However, there is little information available about the clinical efficacy of catheter ablation for paroxysmal AF in patients with significant functional MR.

METHODS

We performed a retrospective study of 247 patients with paroxysmal AF who underwent AF ablation. The study included 28 (11.3%) patients with significant functional MR and 219 (88.7%) without significant functional MR. AF recurrence was defined as the occurrence of confirmed atrial tachyarrhythmia lasting >30 seconds beyond 3 months after catheter ablation.

RESULTS

During a mean follow-up of 20.1 ± 7.4 months (range, 3-36 months), 45 (18.2%) patients developed recurrence of AF. The recurrence rate of AF was higher in patients with significant functional MR than in those without significant functional MR (42.9% vs 15.1%; P < .001). Univariable Cox proportional hazards regression analysis showed that significant functional MR (hazard ratio [HR], 3.46; 95% confidence interval [CI], 1.78-6.72; P < .001), age (HR, 1.04; 95% CI, 1.01-1.08; P = .009), the CHA2DS2-VASc score (HR, 1.28; 95% CI, 1.05-1.56; P = .017), and heart failure (HR, 4.71; 95% CI, 1.85-11.96; P = .001) were associated with the risk of recurrence. Multivariable analysis showed that significant functional MR (HR, 2.48; 95% CI, 1.21-5.05; P = .013), age (HR, 1.04; 95% CI, 1.00-1.07; P = .031), and heart failure (HR, 3.39; 95% CI, 1.27-9.03; P = .015) were independent predictors of AF recurrence.

CONCLUSION

Patients with significant functional MR have an increased risk of AF recurrence after catheter ablation.

Simplified stepwise anatomical ablation strategy for mitral isthmus: efficacy, efficiency, safety, and outcome

AIMS

Bidirectional and durable block of mitral isthmus (MI) is essential for catheter ablation of persistent atrial fibrillation (PeAF) and perimitral flutter (PMF), but it remains a challenge. The aim of this study was to create a simple anatomical ablation strategy with minimal fluoroscopy that would yield a high success rate for MI block.

METHODS AND RESULTS

Patients with PeAF or PMF were included. Mitral isthmus was ablated in a stepwise strategy. In Step 1, endocardial MI linear ablation was performed; in Step 2, ablation was targeted to the posterolateral portion of the left atrium along the MI line; in Step 3, epicardial ablation within the coronary sinus (CS) was performed across the MI line to the ostium of the vein of Marshall (VOM) or performed within the VOM if available; in Step 4, the catheter was rotated and ablated in the CS to isolate the CS; and in Step 5, the early activation site with complex component potential above the MI line during distal CS pacing was considered as the ablation target. All patients were followed up. A total of 178 (17 patients with mechanical prosthetic mitral valve) were included. One hundred and sixty-six patients achieved a confirmed MI bidirectional conduction block (93%). One patient had cardiac tamponade. Four patients showed re-conduction across the MI line during a repeated ablation. In the latest follow-up [12 (7, 16) months], 161 of 178 (90%) patients maintained their sinus rhythm.

CONCLUSION

A simple stepwise anatomical ablation strategy for MI shows a high success rate with low fluoroscopy exposure.

Aetiology of chronic heart failure in patients from a super-aged society: the KUNIUMI registry chronic cohort

AIMS

With the rapidly increasing ageing population, heart failure is an urgent challenge, particularly in developed countries. The study aimed to investigate the main aetiologies of chronic heart failure in a super-aged society.

METHODS AND RESULTS

The KUNIUMI registry chronic cohort is a community-based, prospective, observational study of chronic heart failure in Awaji Island, Japan. Inhabitants of this island aged ≥65 years accounted for 36.3% of the population. In the present study, data from patients with symptomatic heart failure were extracted from the registry. A total of 1646 patients were enrolled from March 2019 to March 2021, accounting for ~1.3% of the inhabitants of Awaji Island. We analysed 852 patients with symptomatic heart failure. The mean age was high (78.7 ± 11.1 years), with 357 patients (41.9%) being female. The proportion of women increased significantly with advancing age and constituted more than half of the patients aged 85 years and older (P < 0.01). The prevalence of atrial fibrillation, and in particular long-standing persistent atrial fibrillation, increased at 70 years of age (P < 0.01). The proportion of patients with heart failure with preserved ejection fraction increased to ~60% when age was over 75 years. Although ischaemic heart disease accounted for 35.0% of chronic heart failure aetiologies, valvular heart disease was the most common cause of chronic heart failure (49.8%). The major types of valvular heart disease were mitral regurgitation and tricuspid regurgitation (27.2% and 21.7%, respectively), both of which increased significantly with age (P < 0.01). The incidence of aortic valve stenosis increased markedly over the age of 85 years (P < 0.01). Atrial functional mitral regurgitation increased with age and was the major cause of mitral regurgitation in patients aged >75 years. Patients with atrial functional mitral regurgitation had a higher prevalence of atrial fibrillation (especially long-standing persistent atrial fibrillation) and a larger left atrial volume index when compared with patients with other types of mitral regurgitation (P < 0.001, respectively).

CONCLUSIONS

The KUNIUMI registry chronic cohort showed a change in heart failure aetiology to valvular heart disease in a super-aged society. Effective and comprehensive countermeasures are required to prepare for the rapid rise in heart failure incidence in a super-aged society.