Rhythm outcomes after catheter ablation for persistent atrial fibrillation in patients with heart failure: results of a prospective registry

Atrial fibrillation (AF) and heart failure (HF) share a closely intertwined pathophysiology. While AF catheter ablation has become a first-line rhythm control strategy in HF with reduced ejection fraction (HFrEF), rhythm outcomes in HF with preserved (HFpEF) and mildly reduced (HFmrEF) ejection fraction remain underreported.

To compare rhythm outcomes 12 months after catheter ablation for persistent AF (persAF) in patients with HFpEF, HFmrEF and without HF off antiarrhythmic drugs (AAD).

We analyzed n=114 consecutive patients referred for first-time catheter ablation of persAF, who were included in a prospective single-center HF registry from April 2022 to July 2023. All patients received standardized clinical assessment, echocardiography and N-terminal pro-B-type natriuretic peptide (NT-proBNP) analysis at baseline and were allocated to 3 groups according to current European guidelines: No HF (n=37), HFpEF (n=46) and HFmrEF (n=31). Pulmonary vein isolation ± additional substrate ablation was performed using radiofrequency ablation (60-70W). Follow-up visits including 7-day Holter ECGs were scheduled at 3 and 12 months.

Mean age was 63.8 ± 11.4 years in patients without HF, 70.4 ± 9.4 in HFpEF and 66.5 ± 6.9 in HFmrEF (p=0.008). Women were significantly more frequent in the HFpEF group (8.1% vs. 54.4% vs. 29.0%, p<0.001). Further baseline characteristics are summarized in Figure 1. Left atrial volume index (36.9 ± 15.2 vs. 51.4 ± 22.2 vs. 51.5 ± 30.3 mL/m2, p=0.008) and low voltage areas (16.9 ± 25.0 vs. 51.9 ± 32.6 vs. 42.3 ± 38.9%, p<0.001) differed significantly between groups. At 12 months, single-procedure freedom from any atrial arrhythmia was 61.8% in No HF vs. 34.1% in HFpEF vs. 33.3% in HFmrEF (Log Rank p=0.023, Figure 2). Sinus rhythm was maintained off AAD in 89.2% vs. 71.1% vs. 74.2% patients (p=0.123). Mean HF-related hospitalizations within 12 months decreased significantly after ablation in both HFpEF (0.5 ± 1.0 vs. 0.07 ± 0.3, p=0.008) and HFmrEF (0.3 ± 0.5 vs. 0.03 ± 0.2, p=0.03).

HFpEF and HFmrEF patients present a more pronounced structural and electrical remodeling than patients without HF. Despite lower single-procedure freedom of any atrial arrhythmia, catheter ablation for persAF is associated with high rates of rhythm control and with significantly decreased HF-related hospitalizations at 12 months in both HFpEF and HFmrEF.Figure 1  Figure 2