Impact of Left Ventricular Function and Heart Failure Symptoms on Outcomes Post Ablation of Atrial Fibrillation in Heart Failure

Abstract

Background - Recent data demonstrates promising effects on left ventricular (LV) dysfunction and LV ejection fraction (EF) improvement following ablation for atrial fibrillation (AF) in patients with heart failure (HF). We sought to study the relationship between LVEF, NYHA class on presentation and the endpoints of mortality and HF admissions in the CASTLE-AF study population. Furthermore, predictors for LVEF improvement were examined. Methods - The CASTLE-AF patients with coexisting HF and AF (n=363) were randomized in a multicenter prospective controlled fashion to ablation (n=179) vs pharmacological therapy (n=184). LV function and NYHA class were assessed at baseline (after randomization) and at each follow-up visit. Results - In the ablation arm, a significantly higher number of patients experienced an improvement in their LVEF to >35% at the end of the study (OR=2.17; p<0.001). Compared to the pharmacological therapy arm, both ablation patient groups with severe (<20%) or moderate/severe (≥20% and <35%)) baseline LVEF had a significantly lower number of composite endpoints (hazard ratio (HR) =0.60; p=0.006), all-cause mortality (HR=0.54; p=0.019) and cardiovascular (CV) hospitalizations (HR=0.66; p=0.017). In the ablation group, NYHA I/II patients at the time of treatment had the strongest improvement in clinical outcomes (primary endpoint: HR=0.43; p<0.001; mortality: HR=0.30; p=0.001). Conclusions - Compared to pharmacological treatment, AF ablation was associated with a significant improvement in LVEF, independent from the severity of LV dysfunction. AF ablation should be performed at early stages of the patient's HF symptoms.

Find Me If You Can: First Clinical Experience Using the Novel CARTOFINDER Algorithm in a Routine Workflow for Atrial Fibrillation Ablation

“…The mechanisms initiating and perpetuating AF are still not completely understood and therefore, ablation strategies are heterogeneous. Several observations have led to individual mechanistic insights in AF management and arrhythmiaassociated cardiac remodeling which emphasize the need for personalized paths in AF therapy [2,3]. Despite improvements in ablation technology, imaging modalities, and ablation techniques, the recurrence of atrial arrhythmias after AF ablation still remains frequent [1,4].…”

Catheter ablation for atrial fibrillation in patients with end‐stage heart failure and eligibility for heart transplantation

“…These observations led to the suggestion that there might be a substantial degree of AF‐induced structural LV remodelling in HF patients and even in those without LV dysfunction. In this context, recent data demonstrated that sinus rhythm after successful AF ablation resulted in reverse LV remodelling and improvement of the LV function as well as HF symptoms 1,20–22 . Irrespective of these findings, open questions remain regarding selection of adequate patients and validity of the findings in patients with terminal HF and severely impaired LV function.…”

“…In this context, recent data demonstrated that sinus rhythm after successful AF ablation resulted in reverse LV remodelling and improvement of the LV function as well as HF symptoms. 1, [20][21][22] Irrespective of these findings, open questions remain regarding selection of adequate patients and validity of the findings in patients with terminal HF and severely impaired LV function. As mentioned earlier, patients with end-stage HF eligible or listed for HTx represent a separate and highly specialized cohort, as these patients have been excluded from all major and guideline relevant clinical trials.…”

Atrial fibrillation and heart failure: A contemporary review of current management approaches

“…Patients with more advanced HF, lower LVEF, and larger atrial size may benefit less from catheter ablation. 64 The role of the hybrid convergent procedure compared to standard catheter ablation in patients with AF and HF also will need to be studied.…”