Improvement of heart failure status and rhythm outcomes after catheter ablation for persistent atrial fibrillation in heart failure with preserved, mildly reduced and reduced ejection fraction

Background
Atrial fibrillation (AF) and heart failure (HF) often coexist and are associated with significant morbidity and mortality. While a benefit of AF catheter ablation has been reported in HF with reduced ejection fraction (HFrEF), it remains less well established in HF with preserved (HFpEF) and with mildly reduced (HFmrEF) ejection fraction.

Aim
To characterize changes in HF status and rhythm outcomes 12 months after ablation of persistent AF (persAF) in HF patients based on systematic clinical, echocardiographic and biomarker assessment.

Methods
We analyzed n=123 consecutive patients referred for first-time catheter ablation of persAF who participated in a prospective single-center HF registry. All patients received standardized clinical assessment, echocardiography and N-terminal pro-B-type natriuretic peptide (NT-proBNP) measurements at baseline and at 12 months. HF classification was performed according to current European guidelines. The ablation procedure included pulmonary vein isolation ± additional substrate ablation using radiofrequency ablation (60-70W).

Results
HF incidence among study participants was 69.9% (HFpEF 37.4% [n=46], HFmrEF 25.2% [n=31], HFrEF 7.3% [n=9]). Mean age was 70.4 ± 9.4 in HFpEF vs. 66.5 ± 6.9 in HFmrEF vs. 65.0 ± 9.6 in HFrEF (p=0.070). Significant differences in female sex (54.4% vs. 29.0% vs. 11.1%, p=0.014), LVEF (55.3 ± 5.5 vs. 45.2 ± 2.8 vs. 33.1 ± 4.3%, p<0.001) and mean 12-month HF-related hospitalization rates (0.4 ± 0.9 vs. 0.3 ± 0.5 vs. 1.3 vs. 0.9, p=0.003) were observed between groups at baseline. Further baseline characteristics are listed in Figure 1. On electroanatomic mapping, relative low voltage area surface was 51.9 ± 32.6 vs. 42.3 ± 38.9 vs. 16.9 ± 17.2% (p=0.036). At 12 months follow-up, sinus rhythm was maintained off antiarrhythmic drugs in 71.1% vs. 74.2% vs. 77.8% of patients (p=0.901). Freedom from any atrial arrhythmia was 34.9% vs. 33.3% vs. 77.8% (p=0.041) after 1 procedure and 65.9% vs. 63.3% vs. 77.7% (p=0.722) after 1 or 2 procedures. NYHA class improvement was found in all groups (69.2% in HFpEF, 63.0% in HFmrEF and 75.0% in HFrEF, p=0.774). LVEF improved significantly in HFmrEF and HFrEF patients, while a significant decrease in LA area and NT-proBNP levels was observed in all groups (Figure 2). The highest relative improvement in LVEF (+12.6 ± 7.0 %, p=0.001), NT-proBNP (-1450 ± 1337 pg/mL, p=0.018) and mean 12-month HF-related hospitalization rate (-1.2 ± 0.9, p=0.005) was observed in the HFrEF group.

Conclusions
Catheter ablation of persAF is associated with high rates of rhythm control and with significant clinical, echocardiographic and biomarker improvements in all heart failure categories. The highest improvement of HF status is found in HFrEF.

Figure 1



Figure 2