Catheter ablation of atrial fibrillation in patients with heart failure - preserved and reduced ejection fraction - real world evidence

Background Catheter ablation for atrial fibrillation (AF) has been shown to reduce mortality and morbidity in patients with AF and heart failure with reduced ejection fraction (HFrEF) compared with medical therapy (GDMT) alone. Outcomes in patients with preserved ejection fraction remain less clearly defined. This study compared long-term outcomes of catheter ablation in patients with AF and heart failure (HF) across the spectrum of ejection fraction using real-world data. Methods This retrospective cohort study utilized the U.S. Collaborative Network in TriNetX to identify adults with AF and HF between September 2018 and September 2024. After 1:1 propensity score matching, 12,492 patients with HFpEF and AF and 38,150 patients with HFrEF were included. The primary endpoint was a composite including all-cause mortality, left-ventricular-assist device implantation, or heart transplantation. Secondary endpoints included hospitalization, stroke, and antiarrhythmic drug (AAD) use. Outcomes were compared between patients receiving ablation and GDMT versus GDMT alone. Results Over a mean follow-up of 973 days (HFpEF) and 926 days (HFrEF), AF ablation was associated with lower risks of the primary endpoint and mortality (HFpEF: hazard ratio (HR) 0.29; HFrEF: HR 0.40; all p < 0.001), as well as reduced hospitalization (HFpEF: HR 0.81; HFrEF: HR 0.75; all p < 0.001) and stroke (HFpEF: HR 0.86, p = 0.025; HFrEF: HR 0.76, p < 0.001). Patients that received ablation had more frequent AAD use despite greater cardioversion rates (HFpEF: HR 1.37; HFrEF: HR 1.08, all p < 0.001). Conclusion Catheter ablation conferred comparable reductions in mortality, advanced HF therapies, stroke, and hospitalization in both HFpEF and HFrEF patients.