Effectiveness of Catheter Ablation for Patients With Atrial Fibrillation and Heart Failure

Q: What does this research mean for the field?

Catheter ablation is associated with significantly reduced all-cause mortality, cardiovascular death, and thromboembolism compared to pharmacological treatment in patients with atrial fibrillation and heart failure. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Le Zhou; Jue Wang; Liu He; Xiangyi Kong; Xin Li; Chao Jiang; Wenli Dai; Lizhu Guo; Guo Xueyuan; Changyi Li; Xin Zhao; Wei Wang; Songnan Li; Chenxi Jiang; Nian Liu; Ribo Tang; Caihua Sang; Deyong Long; Xin Du; Jianzeng Dong; Changsheng Ma

doi:10.1111/pace.70073

Why the study?

The efficacy of catheter ablation versus antiarrhythmic drugs in patients with AF and HFpEF is not conclusively established, requiring real-world evidence across the broader spectrum of HF.

Does catheter ablation reduce all-cause mortality in patients with atrial fibrillation and heart failure compared to pharmacological treatment?

Structured PICO

Does catheter ablation reduce all-cause mortality in patients with atrial fibrillation and heart failure compared to pharmacological treatment?

P

Population

2,529 analyzed patients with atrial fibrillation and heart failure from the China-AF Registry. The propensity score matched cohort included 1,208 patients (604 per group), mean age 62.6 ± 10.5 years, 38.3% female, with 53.3% having persistent AF.

I

Intervention

Catheter ablation (average of 1.16 ± 0.41 procedures)

C

Comparator

Pharmacological treatment approach (antiarrhythmic drug therapy)

O

Outcome

All-cause mortalityhard clinical

Limitations

Residual confounding cannot be excluded
Findings should be interpreted with caution pending confirmation from prospective randomized studies

Implication

In a real-world cohort of patients with atrial fibrillation and heart failure, catheter ablation was associated with significantly lower risks of all-cause mortality, cardiovascular death, and thromboembolism compared to pharmacological therapy.

Abstract

BACKGROUND: Atrial fibrillation (AF) is frequently complicated by heart failure (HF), leading to increased morbidity and mortality. Catheter ablation (CA) has been shown in randomized controlled trials (RCTs) to improve outcomes in selected patients with AF and heart failure with reduced ejection fraction (HFrEF). However, the efficacy of CA compared with antiarrhythmic drug (AAD) therapy in patients with heart failure with preserved ejection fraction (HFpEF) has not been conclusively established. Consequently, real-world evidence is needed to further clarify the potential benefits of CA across the broader spectrum of HF populations. OBJECTIVES: Our research will investigate the impact of CA on the clinical prognosis of patients with AF and HF, compared to a pharmacological treatment approach. METHODS: Patients with AF and HF were prospectively enrolled from August 2011 to December 2020 in the China-AF Registry. The efficacy of CA versus pharmacological treatment was evaluated in propensity score matched (PSM) cohorts using Cox proportional hazards analysis. The primary endpoint was all-cause mortality, with secondary endpoints including thromboembolism and cardiovascular death. RESULTS: From a cohort of 3072 AF and HF patients, 2529 were analyzed (678 underwent CA and 1851 received pharmacological treatment). Propensity score matching resulted in 604 patients per group, well-balanced (mean age 62.6 ± 10.5 years, 38.3% female), with 53.3% having persistent AF. Ablation patients underwent an average of 1.16 ± 0.41 procedures. Over a mean 4.16-year follow-up, CA group saw significantly fewer deaths (4.8% vs. 14.1%; adjusted HR 0.54, 95% CI 0.32-0.91; p < 0.001) compared to the pharmacological group after adjusting potential confounders. CA was also associated with a reduced risk of cardiovascular death (adjusted HR 0.35, 95% CI 0.17-0.74; p = 0.005) and thromboembolism (adjusted HR 0.48, 95% CI 0.26-0.88; p = 0.020), after adjusting medication use. CONCLUSIONS: In patients with AF and HF, CA was associated with improved clinical outcomes compared to pharmacological treatment in this real-world cohort. Nevertheless, residual confounding cannot be excluded, and the findings should be interpreted with caution pending confirmation from prospective randomized studies. TRIAL REGISTRATION: www.chictr.org.cn. Identifier: ChiCTR-OCH-13003729.