Periprocedural safety of atrial fibrillation catheter ablation during hospitalization for acute heart failure: a nationwide analysis using the JORAD-PDC database

Background Catheter ablation for atrial fibrillation (AF) in patients with concomitant heart failure has been shown to be effective, and early intervention may potentially improve subsequent clinical outcomes. However, evidence regarding the periprocedural safety of AF ablation during acute heart failure hospitalization remains limited. Objective This study aimed to evaluate the periprocedural risks associated with AF catheter ablation performed during hospitalization for acute heart failure. Methods Using the Japanese Registry of All Cardiac and Vascular Diseases (JROAD) and JROAD Diagnosis Procedure Combination (JROAD-DPC), we identified 452,703 patients who underwent their first catheter ablation for AF between April 2012 and March 2024. Patients aged ≤20 years, those who underwent multiple ablations during the same hospitalization, and those admitted to the ICU/CCU, receiving mechanical circulatory support, mechanical ventilation, or oxygen therapy before ablation were excluded. Among them, patients who underwent ablation during hospitalization for acute heart failure (n = 3,696) were compared with those with a history of heart failure who were admitted electively (n = 47,241). The primary outcomes were thromboembolic events, major bleeding, and in-hospital mortality. Inverse Probability of Treatment Weighting (IPTW) was used to adjust for baseline differences between groups. Results Compared with the elective admission group, the acute heart failure group was older (72.6 ± 10.9 vs 68.9 ± 10.5 years, p < 0.001), included more women (42.6% vs 33.6%, p < 0.001), had a lower BMI (23.6 vs 24.3, p < 0.001), a higher proportion of paroxysmal AF (41.2% vs 36.7%, p < 0.001), a higher CHADS2 score (2.31 vs 2.05, p < 0.001), and a higher rate of cryoballoon ablation (20.6% vs 17.9%, p < 0.001). After adjustment using IPTW, atrial fibrillation ablation performed during hospitalization for acute heart failure was associated with an increased risk of periprocedural complications compared with elective admissions. The odds ratio for thromboembolic events was 2.46 (95% confidence interval [CI]: 1.68–3.61, p = 0.017). For major bleeding, the odds ratio was 1.73 (95% CI: 1.27–2.35, p = 0.002). In-hospital mortality was higher in the acute heart failure group, with an odds ratio of 2.60 (95% CI: 1.11–6.12, p = 0.028). The absolute risk differences for thromboembolic events, major bleeding, and in-hospital mortality were +1.11%, +0.82%, and +0.16%, respectively. Conclusion Catheter ablation for AF performed during acute heart failure hospitalization was associated with increased risks of thromboembolic events, major bleeding, and in-hospital mortality. Careful evaluation of the risk–benefit balance is warranted when considering AF ablation in the acute phase of heart failure, and individualized assessment of optimal intervention timing is essential.