Catheter ablation in patients with atrial fibrillation and heart failure with preserved ejection fraction: A systematic review and meta‐analysis

Abstract

Background Catheter ablation for atrial fibrillation (AF) is a proven alternative to pharmacologic rhythm control in patients with heart failure with reduced ejection fraction (HFrEF). Whether outcomes differ in patients with heart failure with preserved ejection fraction (HFpEF) is of interest. Methods Medline, Scopus, and Cochrane Central Register of Controlled Trials were systematically searched to identify relevant studies. Primary efficacy outcomes of interest include atrial arrythmia recurrence and repeat ablation. Harm outcomes of interest include all‐cause mortality, all‐cause hospitalizations, cardiovascular hospitalizations, stroke/transient ischemic attack, and cardiac tamponade. Results We included 7 observational studies comprising 2554 patients with HFpEF who underwent catheter ablation for AF. When comparing patients with HFpEF versus without HF, there was no significant difference in atrial arrhythmia recurrence (risk ratio [RR] 1.39; 95% confidence interval [CI] 0.91–2.13), stroke or transient ischemic attack (TIA) (RR 0.47; 95% CI 0.03–6.54), or cardiac tamponade (RR 1.20; 95% CI 0.12–12.20). When comparing patients with HFpEF versus HFrEF, there was no significant difference in atrial arrhythmia recurrence (RR 1.12; 95% CI 0.92–1.37), repeat ablation (RR 1.19; 95% CI 0.74–1.93), all‐cause mortality (RR 0.87; 95% CI 0.67–1.13), all‐cause hospitalizations (RR 1.10; 95% CI 0.94–1.30), cardiovascular hospitalizations (RR 0.83; 95% CI 0.69–1.01), stroke or TIA (RR 0.81; 95% CI 0.29–2.25), or cardiac tamponade (RR 0.98; 95% CI 0.19–5.16). Conclusions Non‐randomized studies suggest that catheter ablation for AF in patients with HFpEF is associated with similar arrythmia‐free survival and safety profile when compared to patients with HFrEF or without heart failure.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

“…A meta-analysis on catheter ablation in patients with HFpEF that included 7 studies and 764 patients showed the ablation to be safe and effective and associated with lower hospitalizations and the mortality rate. 15…”

Heart failure and atrial fibrillation: Is atrial fibrillation ablation in heart failure pointless or mandatory?

“…Siddiqui et al 30 performed a meta‐analysis of seven observational non‐randomized studies comprising 2554 patients with HFpEF who underwent CA for AF. When comparing patients with HFpEF versus those without HF, there was no significant difference in atrial arrhythmia recurrence (RR: 1.39, 95% CI: 0.91–2.13) and stroke (RR: 0.47, 95% CI: 0.03–6.54).…”

“…When comparing patients with HFpEF versus those without HF, there was no significant difference in atrial arrhythmia recurrence (RR: 1.39, 95% CI: 0.91–2.13) and stroke (RR: 0.47, 95% CI: 0.03–6.54). Similarly, when comparing patients with HFpEF versus HFrEF, there was no significant difference in atrial arrhythmia recurrence (RR: 1.12, 95% CI: 0.92–1.37), repeat ablation (RR: 1.19, 95% CI: 0.74–1.93), all‐cause mortality (RR: 0.87, 95% CI: 0.67–1.13), all‐cause hospitalizations (RR: 1.10, 95% CI: 0.94–1.30), and cardiovascular hospitalizations (RR: 0.83, 95% CI: 0.69–1.01) 30 …”

“…In another randomized small cohort study (n = 31) by Chieng et al, 29 While no differences were detected in the primary and secondary outcomes in the medical arm, 50% of patients no longer met exercise right heart catheterization-based criteria for HFpEF with CA versus 7% in the medical arm (p = .02). 29 Siddiqui et al 30 performed a meta-analysis of seven observational non-randomized studies comprising 2554 patients with HFpEF who underwent CA for AF. When comparing patients with HFpEF versus those without HF, there was no significant difference in atrial arrhythmia recurrence (RR: 1.39, 95% CI: 0.91-2.13) and stroke (RR: 0.47, 95% CI: 0.03-6.54).…”

“…Similarly, when comparing patients with HFpEF versus HFrEF, there was no significant difference in atrial arrhythmia recurrence (RR: 1.12, 95% CI: 0.92-1.37), repeat ablation (RR: 1.19, 95% CI: 0.74-1.93), all-cause mortality (RR: 0.87, 95% CI: 0.67-1.13), all-cause hospitalizations (RR: 1.10, 95% CI: 0.94-1.30), and cardiovascular hospitalizations (RR: 0.83, 95% CI: 0.69-1.01). 30 A pooled data of patients with HFmrEF and HFpEF who underwent AF ablation from two Japanese multicenter registries, AF Frontier Ablation Registry (n = 525) and Hokuriku-Plus AF Registry (n = 374) showed that at follow-up of 24.6 months, the CA group had a significantly lower incidence of the primary composite endpoint of cardiovascular death and hospitalization for HF (HR: 0.32, 95% CI: 0.13-0.70, p = .004) than the medical therapy group. 31 In the CABANA (Catheter Ablation vs. Antiarrhythmic Drug Therapy for Atrial Fibrillation) trial, there were 778 patients with HF who were randomized to ablation or drug therapy, and in 571 patients in whom data on index EF was available.…”