Disclosures: No conflict to disclose.
Key words: HFpEF, atrial fibrillation, cardioversion, cardiac damage
Background: Previous studies suggest that staging cardiac damage prior structural heart interventions (e.g. transcatheter aortic valve repair) may provide valuable insights into patient stratification and treatment efficacy. In this study, we investigated the distribution and prognostic relevance of the extent of cardiac damage in HFpEF patients undergoing catheter ablation for atrial fibrillation.
Methods: The clinical, echocardiographic and outcome data of patients with atrial fibrillation and left ventricular ejection fraction (LVEF) >40% who underwent first time catheter ablation were analyzed. According to the extent of cardiac damage on echocardiography, patients were classified into 5 groups: No cardiac damage (stage 0), left ventricular damage (stage I), mitral valve or left atrial damage (stage II), tricuspid valve or pulmonary artery vasculature damage (stage III), right ventricular damage (stage IV). All-cause mortality, hospitalization for heart failure and atrial arrhythmia recurrence were analyzed during one-year follow-up.
Results: Five hundred sixty-six patients (mean age 76.7 ± 10.6 years; female 39.6%; mean LVEF 56.15 ± 7.90%) were included. Forty-five patients (8.0%) were classified in stage 0, 59 patients (10.4%) in stage I, 175 patients (30.9%) in stage II, 71 patients (12.5%) in stage III and 216 patients (38.2%) in stage IV. Recurrence of atrial arrhythmias was higher in patients with advanced cardiac damage (stage 0: 14.0%; stage 1: 23.5%; stage 2: 23.0%; stage 3: 37.7%; stage 4: 30.9%; p=0.004). Similarly, with advanced cardiac damage, mortality and HF hospitalization rates increased (stage 0: 5.3%; stage 1: 8.6%; stage 2: 18.3%; stage 3: 11.5%; stage 4: 19.2%; p=0.027). Predictors of atrial arrhythmia recurrences were BMI (HR 1.036 (1.005-1.065), p=0.015), persistent atrial fibrillation (HR 1.615 (1.081-2.421), p=0.019), hemoglobin (HR 0.877 (0.778-0.992), p=0.035), and cardiac damage stage (HR 1.203 (1.050-1.380), p=0.008). Predictors of mortality and HF-hospitalisation were hemoglobin (HR 0.744 (0.628-0.886), p<0.001), troponin (HR 1.003 (1.000-1.005), p=0.005), left atrial volume index (HR 1.019 (1.000-1.038), p=0.041), and cardiac damage stage (HR 1.300 (1.069-1.589), p=0.009).
Conclusion: In patients with HFpEF undergoing catheter ablation for atrial fibrillation, increasing stages of cardiac damage were associated with higher rates of arrhythmia recurrence, mortality, and heart failure hospitalization during follow-up. Cardiac damage staging demonstrated independent prognostic value beyond established clinical markers and may serve as a practical tool to improve risk stratification, guide therapeutic decision-making, and optimize patient selection for atrial fibrillation ablation in HFpEF.
