Atrioventricular nodal ablation with pacemaker implant is associated with improved safety outcomes compared to pulmonary vein isolation of atrial fibrillation with heart failure

Abstract

Abstract Background Pulmonary vein isolation (PVI) and atrioventricular nodal ablation (AVNA) with pacemaker implant have both been advocated for patients with atrial fibrillation (AF) and heart failure with reduced ejection fraction (HFrEF). Direct comparisons between the two are limited. Purpose We sought to compare outcomes and complications following PVI versus AVNA with implant of a cardiac implantable electronic device (CIED) among patients with AF and HFrEF. Methods We queried the National Inpatient Sample from 2011 to 2019, using relevant ICD-9 and -10 diagnostic and procedural codes for AF, HFrEF, ablation, and CIED implant to identify our study cohort. Exclusion criteria included presence of a pre-existing CIED, ventricular arrhythmias, non-AF supraventricular arrhythmias, and surgical AF ablation. Baseline characteristics included age, sex, race, and comorbidities related to AF and cardiovascular disease. Severity of comorbidities was assessed via Deyo-Charlson Comorbidity Index (Deyo-CCI). Outcomes investigated include all-cause mortality, major adverse cardiovascular events (MACE), extra-cardiac procedural complications, length of stay, and total hospital charges. Outcomes associations were analyzed using multivariate logistic regression adjusted for baseline characteristics that were significantly different (P<0.05) between cohorts expressed as adjusted odds ratios (aOR) and 95% confidence intervals (CI). SPSS v28.0 (IBM, Armonk, NY) was used to carry out all calculations. Results We identified 3,565 encounters for PVI and 1,355 for AVNA with CIED implant among hospitalized patients with AF and HFrEF. Patients who underwent AVNA were more often older (73.8 vs 66.2 years), with more severe comorbidities (mean Deyo-CCI score 2.9 vs 2.6) and were more likely to have an emergent procedure performed (81.3% vs 69.7%; p<0.001 for all). However, the AVNA cohort had less mortality (0.5% vs 1.2%, p=0.03), MACE (6.1% vs 7.8%, p=0.04), and total complications (12.7% vs 16.3%, p=0.002), but longer hospital stay (8.0 vs 6.5 days) and higher total charges ($201,100 vs $159,382; p<0.001 for both). After adjusting for confounders, AVNA remained independently associated with decreased odds of mortality (aOR: 0.370; 95% CI [0.159–0.862], p=0.02), MACE (aOR: 0.552; 95% CI [0.420–0.726], p<0.001), and total complications (aOR: 0.708; 95% CI [0.589–0.852], p<0.001). Conclusion Despite older age with more severe comorbidities and less elective procedures, hospitalized patients with AF and HFrEF who underwent AVNA with CIED implant had improved safety outcomes compared to PVI. Further studies comparing the intermediate and long-term outcomes and efficacy between therapies are needed to better delineate which would best serve this population. Funding Acknowledgement Type of funding sources: None.