Impact of atrial fibrillation ablation in heart failure with reduced ejection fraction

Abstract

Abstract Introduction Atrial fibrillation (AF) is the most common supraventricular arrhythmia in patients with heart failure (HF) and is associated with a significant increase in morbidity and mortality. Some studies have shown evidence in favor of ablation over pharmacological treatment in patients with AF and reduced ejection fraction (HFrEF). However, little is known about the generalizability of the trial results to routine clinical practice, particularly in a low- and middle-income country. Objective To evaluate whether catheter ablation (CA) of AF reduces morbidity and mortality compared to medical therapy alone in patients with HFrEF and AF in a real-word contemporary cohort from Argentina. Methods We consecutively identified patients with HF with ejection fraction less than 40% associated with paroxysmal or persistent AF who presented to our hospital, either as outpatients or inpatients, between February 2018 and June 2020. Baseline characteristics and outcomes were compared among patients undergoing CA or medical therapy alone. The primary outcome was all-cause mortality and first HF hospitalization until completing a 3-year follow-up. Propensity score overlap weighting was used to balance ablated and drug-treated patients on sex, age, body mass index, hypertension, diabetes, dyslipidemia, smoking, previous atrial fibrillation ablation, use of antiarrhythmic drugs, cardiac resynchronization, cardiac defibrillator, left ventricular ejection fraction, cardiovascular surgery, infarction, stroke, peripheral vascular disease, etiology of heart failure, respiratory disease and renal disease baseline characteristics. Results Data from 6297 patients with AF were analyzed, of whom 430 had ejection fraction ≤ 40%. We excluded 20 patients who were ablated for atrial flutter. 53 patients in the ablation and 357 patients in the medical therapy group were identified. After PS matching, the primary outcome occurred in 9 patients (23,7%) in the ablation group and in 19 patients (50%) in the control group. Catheter ablation was associated with a statistically significant reduction of the primary outcome in a 3-year follow up (Hazard ratio [HR] 0.33 [95%CI, 0.12-0.93]). Conclusion Catheter ablation for atrial fibrillation in patients with HFrEF was associated with decreased risk of mortality and heart failure hospitalisations relative to medical therapy.Kaplan-Meier survival estimates