CATHETER ABLATION OF ATRIAL FIBRILLATION IN HEART FAILURE WITH REDUCED EJECTION FRACTION: A SYSTEMATIC REVIEW AND META-ANALYSIS

Abstract

There is growing evidence that Atrial Fibrillation (AF) ablation may result in improved outcomes in select patients with AF and heart failure with reduced ejection fraction (HFrEF). The objective of this study was to examine the impact of AF ablation on mortality, hospitalization rate, left ventricular ejection fraction (LVEF), and quality of life in patients with HFrEF, compared to contemporary alternative treatment modalities. We conducted a systematic review and meta-analysis of trials that randomized patients with HFrEF (LVEF ≤40%) to an AF ablation arm or an alternative treatment modality (medical rate control, medical rhythm control, AV node ablation with biventricular pacing). Two independent reviewers extracted study data and performed quality assessments using Grading of Recommendations and the Cochrane Risk Bias Tool. We reported changes on the following outcomes: mortality, heart failure (HF) hospitalization rate, LVEF improvement, quality of life as measured by the Minnesota living with heart failure questionnaire (MLHFQ), six-minute walk test (6MWT), procedural efficacy, and complication rate per procedure. 2009 unique records were identified and screened, and 12 were selected for full text review. Ultimately, seven moderate to high quality randomized controlled trials with 856 patients met inclusion criteria. Four studies used medical rate control as a comparator group, while the three remaining studies used medical rhythm control, either medical rate or rhythm control, and AV node ablation with biventricular pacing, respectively. There were significantly reduced rates of HF-related hospitalization (RR 0.58; CI 0.46,0.74; p<0.001) and all-cause mortality (RR 0.51; CI 0.35,0.75; p<0.001) with AF ablation. Additionally, there was improvement in LVEF (mean difference 7.6%; CI 3.9,11.3; p<0.001) with AF ablation compared to alternative therapies. AF ablation was superior in enhancing quality of life based on MLHFQ scores (mean difference -9.8 points; CI -15, -4.5; p<0.001), and there was a greater reduction in BNP levels post-AF ablation compared to other modalities (mean difference -138.1pg/ml; CI -223, -53; p=0.001). There were 50 procedural complications in a total of 555 ablation procedures performed, culminating in a complication rate of 9.0%. The pooled mean procedural efficacy for the first and final ablations were 61.2% and 74.4%, respectively. In selected patients with AF and HFrEF, AF ablation is associated with a substantial improvement in mortality, HF-hospitalization rate, left ventricular function, and quality of life. Consideration should be given for referral of these patients for assessment of AF ablation candidacy.View Large Image Figure ViewerDownload Hi-res image Download (PPT)