Catheter Ablation of Atrial Fibrillation in Patients With Heart Failure and Preserved Ejection Fraction

Abstract

Background: Coexistence of atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF) is common, affecting morbidity and prognosis. This study evaluates outcome after cryoballoon ablation for AF in HFpEF compared with patients without heart failure. Methods: A total of 102 AF patients with left ventricular ejection fraction ≥50% undergoing cryoballoon ablation were prospectively enrolled. Baseline evaluation included echocardiography, stress echocardiography, 6-minute walk test, biomarkers, and quality of life assessment (Short-Form-36). Procedural parameters and clinical, functional and echocardiographic end points at follow-up ≥12 months after AF ablation were compared between patients with and without HFpEF. Results: Patients with HFpEF (n=24) were older (median, 74 years versus 65 years; P =0.001) more often female (83% versus 28%; P <0.001) and characterized by more pronounced AF-related symptoms (median European Heart Rhythm Association score 3 versus 2; P <0.001), higher left atrial pressures (median, 14 mm Hg versus 10 mm Hg; P =0.008), reduced left atrial-appendage velocity (median, 36 cm/s versus 59 cm/s; P <0.001), and reduced distance in the 6-minute walk test (median, 488 m versus 539 m; P <0.001). Patients with HFpEF more often experienced AF recurrence (57% versus 23%; P =0.003), repeat AF ablation (39% versus 14%; P =0.01) and AF-related rehospitalization (26% versus 7%; P =0.016). Heart failure symptoms and elevated cardiac biomarkers persisted, even in patients with HFpEF with successful rhythm control at follow-up. Echocardiographic follow-up showed progression of adverse left atrial remodeling and no relevant improvement in diastolic function in HFpEF. Quality of life improved in patients without HFpEF, whereas patients with HFpEF still exhibited a lower physical component summary score (median, 41.5 versus 53.4; P <0.004). Conclusions: Patients with HFpEF constitute a distinct subgroup with elevated risk for AF recurrence after cryoballon ablation. Functional hallmarks of HFpEF persist, irrespective of rhythm status at follow-up. Future research is needed to optimize treatment strategies in patients with HFpEF. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT04317911.

Is There a Role for Catheter Ablation of Atrial Fibrillation in the Treatment of Patients With Heart Failure and Preserved Ejection Fraction?

“…In summary, Zylla et al 6 should be commended on a well-conducted hypothesis-generating study that highlights the importance of identifying HFpEF in patients with symptomatic AF. The lack of observed benefit for AF ablation does not exclude AF as a potential therapeutic target in some patients with HFpEF.…”

“…Zylla et al 6 have reported what is often suspected: that AF may be a marker of worse HFpEF in patients with both conditions and targeting AF may not have a meaningful impact in this population. Yet they stand alone among published observational studies which mostly report positive effects of AF ablation on symptoms, QOL, LV diastolic dysfunction, and even reduced HF hospitalization rates among patients with HFpEF.…”

“…13 AF is recognized to induce atrial structural and electrical remodeling that promotes AF (AF begets AF) and Reddy et al 14 described a unique mechanism of LA hypertension in patients with permanent AF and very large atria, mediated by pericardial restraint and heightened ventricular interaction. Zylla et al 6 provide intriguing data showing progressive LA remodeling after ablation in HFpEF, confined to those in AF at follow-up, assuming equal rhythm surveillance. 6 In theory, eliminating AF might prevent or attenuate such AF-driven LA remodeling in HFpEF.…”

“…Zylla et al 6 provide intriguing data showing progressive LA remodeling after ablation in HFpEF, confined to those in AF at follow-up, assuming equal rhythm surveillance. 6 In theory, eliminating AF might prevent or attenuate such AF-driven LA remodeling in HFpEF. In reality, however, there is a competing, and arguably dominant, global cardiomyopathy in HFpEF, involving the LA, related to systemic and metabolic derangements, endothelial inflammation, coronary microvascular disease, and atrial and ventricular fibrosis (Figure).…”

Atrial fibrillation ablation in patients with heart failure with preserved ejection fraction: Complexities in diagnosis and treatment

“…The limited diagnosis of HFpEF is highlighted by the fact that only 4.5% of the cohort had HFpEF, inconsistent with previous studies utilising noninvasive HFpEF scoring tools or invasive hemodynamic assessment, which have shown the prevalence of HFpEF in AF ablation cohorts to be considerably higher. 6 , 7 HFpEF has likely therefore been underdiagnosed in this study, and potentially limited to a sicker cohort. As a result, the rate of complications may not reflect that of an HFpEF cohort diagnosed more stringently.…”