Impact of Timing of Atrial Fibrillation Ablation on AF Recurrence and Clinical Outcomes in Patients With HFpEF and HFrEF

Q: What does this research mean for the field?

Delayed catheter ablation for atrial fibrillation is associated with higher recurrence rates compared to early ablation in both HFrEF and HFpEF patients, without significantly altering stroke, heart failure hospitalization, or mortality rates. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Mahmoud Eisa; Hossam Elbenawi; Momina Iftikhar; Ahmed El Shaer; Muhammad Eltony; Omar Almaadawy; Amro Aglan; Mahmoud Ahmed; Khaled Elfert; Mahmoud Shadi; Ch. Mohan Rao; Justin Z. Lee; Zain Ul Abideen Asad; Freddy Del‐Carpio Munoz; Konstantinos C. Siontis; Mark S. Link; Abhishek Deshmukh; Christopher V. DeSimone

doi:10.1111/jce.70166

Why the study?

Early catheter ablation for AF improves outcomes, but the optimal timing across heart failure subtypes (HFrEF and HFpEF) remains unclear.

Does early catheter ablation reduce AF recurrence compared to delayed ablation in patients with heart failure and atrial fibrillation?

Structured PICO

Does early catheter ablation reduce AF recurrence compared to delayed ablation in patients with heart failure and atrial fibrillation?

P

Population

Heart failure patients (HFrEF and HFpEF) with atrial fibrillation who underwent catheter ablation

I

Intervention

Early catheter ablation (≤ 1 year of first AF diagnosis)

C

Comparator

Delayed catheter ablation (1-3 years of first AF diagnosis)

O

Outcome

AF recurrence, defined by repeat ablation, direct current cardioversion (DCCV), or antiarrhythmic drug (AAD) use after a 3-month blanking periodcomposite

Early catheter ablation (≤ 1 year of diagnosis) for AF in patients with HFpEF and HFrEF is associated with lower AF recurrence compared to delayed ablation, though stroke and mortality rates are similar.

Implication

Supports earlier ablation timing in HF-AF; hypothesis-generating and requires randomized confirmation before practice change.

Abstract

BACKGROUND: Early catheter ablation for atrial fibrillation (AF) improves outcomes, but the optimal timing, especially in heart failure (HF) subtypes, remains unclear. OBJECTIVE: To evaluate the impact of ablation timing on outcomes in patients with HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF). METHODS: We used the TriNetX database (2010-2024) to identify HF patients with AF who underwent ablation. Patients were classified as early ablation (≤ 1 year of first AF diagnosis) or delayed ablation (1-3 years), with propensity score matching (PSM) applied to balance the baseline characteristics. The primary outcome was AF recurrence, defined by repeat ablation, direct current cardioversion (DCCV), or antiarrhythmic drug (AAD) use after a 3-month blanking period. Secondary outcomes included stroke, hospitalization, and mortality over 5 years. RESULTS: After PSM, delayed ablation was associated with higher AF recurrence in both HFrEF (HR = 1.28, p < 0.001) and HFpEF (HR = 1.21, p = 0.02), as seen in multivariate analysis. In HFrEF, delayed ablation was associated with higher incidence of re-do ablation, AAD use, and DCCV, while in HFpEF, higher recurrence with delayed ablation was associated with increased AAD use. Both cohorts had similar stroke and mortality rates between early and delayed ablation. CONCLUSIONS: Delayed ablation in HFrEF and HFpEF was linked to higher AF recurrence, driven by increased redo ablations, DCCV, AAD use in HFrEF, and higher AAD use in HFpEF. Stroke, HF hospitalization and mortality rates were similar, suggesting earlier ablation may enhance rhythm control over other outcomes.