Atrial fibrillation recurrence pattern and subsequent heart failure hospitalization after ablation in left ventricular systolic dysfunction: A time-dependent analysis

Catheter ablation improves outcomes in patients with atrial fibrillation (AF) and left ventricular (LV) systolic dysfunction, but the prognostic significance of postablation recurrence pattern and its evolution remains unclear. We investigated whether evolving postablation recurrence pattern was associated with subsequent heart failure (HF) hospitalization. This retrospective single-center study included 381 of 5535 consecutive patients who underwent first-time AF ablation between 2012 and 2024 and had baseline left ventricular ejection fraction (LVEF) <50%. Recurrence was defined as any atrial tachyarrhythmia lasting >30 s beyond the 3-month blanking period and classified as paroxysmal or persistent (lasting >7 days). Recurrence pattern was modeled as a time-dependent variable and updated upon documentation of paroxysmal or persistent recurrence during follow-up. During a median follow-up of 49 months, 140 patients experienced recurrence (71 paroxysmal only and 69 persistent, including 21 who progressed from paroxysmal to persistent recurrence) and 61 experienced HF hospitalization. In a multivariable time-dependent Cox model adjusted for age, sex, baseline LVEF, prior myocardial infarction, prior HF hospitalization, and baseline AF type, both paroxysmal recurrence [hazard ratio (HR), 2.38; 95% confidence interval (CI), 1.15-4.90; p = 0.019] and persistent recurrence (HR, 5.45; 95% CI, 2.59-11.46; p < 0.001) were associated with HF hospitalization compared with no recurrence. Persistent recurrence was also associated with a higher risk than paroxysmal recurrence (HR, 2.29; 95% CI, 1.00-5.25; p = 0.049). Time-updated assessment of postablation AF recurrence pattern revealed differential risks of subsequent HF hospitalization among patients with LV systolic dysfunction. Both paroxysmal and persistent recurrence were associated with HF hospitalization, with persistent recurrence representing a particularly high-risk state that may warrant closer HF surveillance and reassessment of rhythm-control strategies.