Heart failure hospitalizations and diuretic use before and after first-time pulmonary vein isolation ablation for atrial fibrillation among patients with heart failure

Background

Small randomized clinical trials have found that patients with heart failure (HF) and atrial fibrillation (AF) randomized to an ablation strategy for AF experienced improved cardiovascular outcomes. We examined the relation in routine clinical practice.

Purpose

We aimed to assess if first-time pulmonary vein isolation ablation (PVI) for AF among patients with HF was associated with decrease in HF hospital admissions rates and furosemide dosage in the year after PVI compared with the year before.

Methods

We identified patients with HF and available left ventricular ejection fraction (LVEF) treated with a first-time PVI using the Danish Ablation Registry, and alive at 1-year follow-up. Patient comorbidities and concomitant pharmacotherapy (including furosemide dosage and HF hospital admissions) were identified utilizing Danish nationwide registries. For inclusion, patients were required to have been diagnosed with HF in an in- or outpatient setting <10 years of first-time PVI or have a LVEF at the time of PVI ≤45%. Patients were grouped according to LVEF at time of PVI: ≤35%, 36–45%, and >45%. For comparison of HF hospital admission and furosemide usage before and after PVI, McNemars test were used. Wilcox signed-rank test were used to test difference in furosemide dosage before and after PVI.

Results

We identified 668/3450 patients with HF treated with first-time PVI for AF between 2010–2017 (median age 62 years [Q1,Q3=56,69 years], 81% male, and median LVEF 45% [Q1,Q3=40,60%]). Of these, 13 patients (2%) died during one-year follow-up. Overall, 36% of patients with HF had one or more HF hospital admissions the year before PVI compared with 7% in the year after PVI (p<0.0001) (Figure 1). Patients with LVEF ≤35% had the highest proportion of HF hospital admissions the year before PVI (53%) and was reduced more than 4-fold (13%) in the year after first-time PVI, with consistent findings in all LVEF groups (Figure 1). At the time of PVI, 36% of patients with HF were treated with furosemide compared with 30% in the year after PVI (p<0.0001) (Figure 2). Moreover, we identified significant reductions in furosemide dose in the year after PVI compared with the year before (median dose 60 mg [Q1,Q3=30,80 mg] and 20 mg [Q1,Q3=0,60 mg], respectively, p=0.001). Here, reductions in furosemide requirements were consistent across LVEF subgroups.

Conclusion

Patients with HF treated with a first-time PVI strategy for AF had a 5-fold decrease in HF hospital admissions in the following year compared with the year before PVI. Among patients treated with furosemide at time of PVI, significant reductions in dose one year after PVI was identified but also significant reductions in proportion of patients requiring any furosemide at all.

Funding Acknowledgement

Type of funding sources: None.

Early mortality and complications following first-time catheter ablation of atrial fibrillation in a nationwide cohort

Funding Acknowledgements

Type of funding sources: None.

Background

Atrial fibrillation (AF) is the most common clinical arrhythmia. Pulmonary vein isolation (PVI) by catheter ablation has become a cornerstone in the treatment of AF. Serious complications to PVI have been reported to be at an acceptable level and risk of death after AF ablation is low.

Purpose

In a contemporary nationwide cohort of patients undergoing first-time PVI by catheter ablation, we wanted to investigate the 30-day mortality after ablation, and to examine risk and potential risk factors of PVI-related complications.

Methods

Population-based cohort study in patients who underwent first-time PVI by catheter ablation between 2011-2018 identified from the National Danish Ablation Registry. Primary outcome was early post-procedural mortality, defined as death of any cause within 30 days of index PVI procedure, or in connection to a hospitalization started within 30 days. Secondary outcomes were all-cause rehospitalization and complication, including postoperative infection, cardiac, vascular, neurological, vascular, and pulmonary complications within 30 days. Data on mortality and complications were collected from national health and administrative registries. Binary regression was used to estimate risk ratio (RR) with 95% confidence intervals (CI) for association between selected predictors and any complication, and adjusted gender, age, BMI, prior ablation, calendar period (ablation from 2011-2013, 2014-2016, and >2016).

Results

We included 8560 patients. Median age was 62, 66% were men, 12% had a history of heart failure, and median CHA2DS2VASc score was 1 (Interquartile range [IQR]; 1-2). Charlton Comorbidity index (CCI) was none in 66%, moderate in 29% and severe in 5%. A total of 10 (0.12%) patients died within 30 days of ablation, of which 4 patients died during initial hospitalization. Median time to death was 20 (IQR, 12 to 29) days. Patients who died were more likely to have experienced a procedure-related complication (40% vs. 4%, P<0.001). Procedure-related complications occurred in 298 (3.5%), and the risk was 4.4%, 3.0% and 3.3% in the time periods between 2011-2013, 2014-2016 and >2016, respectively. Most common complications were postoperative infection (26%), cardiac complication (26%), and vascular complications (18%). Complication risk was increased in patients with higher age (aRR, 65-74 year; 1.67 [1.32-2.11] and >74 years; 2.48 [1.60-3.84]), moderate CCI (aRR 1.45 [1.14-1.83]), cardiovascular disease (aRR 1.52 [1.09-2.11]) and antithrombotic treatment (aRR 1.41 [1.05-1.89]). After first-time PVI, 1.963 (23%) patients were re-hospitalized within 30 days, and most common primary discharge diagnoses were AF (87%) and direct cardioversion was performed in 765 (39%) patients.

Conclusion

In a nationwide cohort of patients who underwent first-time PVI, number of deaths within 30 days of ablation was low (0.12%). Risk of complication was low and 23% of the patients were re-hospitalized within 30 days.