Right-heart reverse remodeling and heart failure symptom outcomes after catheter ablation in patients with persistent atrial fibrillation, heart failure, and functional tricuspid regurgitation

Background: Persistent atrial fibrillation (AF) and heart failure (HF) may promote right-heart remodeling and functional tricuspid regurgitation (FTR). Evidence regarding right-heart changes after first AF ablation in patients with persistent AF, HF, and FTR remains limited. This study assessed 12-month right-heart reverse remodeling and its associations with HF symptoms and exploratory clinical events. Methods: This retrospective single-center cohort included 210 patients with persistent AF, HF with reduced, mildly reduced, or preserved ejection fraction, and at least mild FTR undergoing first catheter ablation. Transthoracic echocardiography (TTE) was performed at baseline and 12 months. Significant right-heart reverse remodeling was defined as a ≥10% reduction in right atrial volume index (RAVI) plus a ≥10% reduction in right ventricular (RV) basal diameter or tricuspid annular diameter, without worsening tricuspid regurgitation (TR) or RV function. Logistic regression, rhythm/loading and threshold sensitivity analyses, and 12-month landmark Cox models were used. Results: At 12 months, RAVI changed by -19.3% [interquartile range (IQR), -30.5% to -6.8%]; 93 patients (44.3%) achieved remodeling, 57.1% had TR improvement, and 61.0% had HF symptom improvement. Sinus rhythm during echocardiography increased from 16.7% to 78.6%, while heart failure guideline-directed medical therapy (HF-GDMT) and sodium-glucose cotransporter 2 (SGLT2)-inhibitor use increased. Same-rhythm and rhythm/loading-adjusted analyses showed directionally consistent but attenuated improvements in right-heart dimensions, pulmonary artery systolic pressure, and TR grade. Long-standing persistent AF, higher baseline RAVI, higher pulmonary artery systolic pressure, and arrhythmia recurrence within 12 months were associated with lower odds of remodeling, whereas higher estimated glomerular filtration rate (eGFR) and HF-GDMT were associated with higher odds. After the 12-month landmark, arrhythmia recurrence and HF rehospitalization were less frequent with remodeling. Conclusions: In this single-arm retrospective cohort, right-heart reverse remodeling observed after first AF ablation was associated with TR improvement, HF symptom improvement, and lower exploratory post-landmark event rates. The single-arm design, rhythm/loading changes, HF-GDMT intensification, and short post-landmark follow-up support associative and hypothesis-generating interpretation; causal attribution requires prospective controlled studies.