Urgent DC Cardioversion or Ablation for Atrial Fibrillation or Atrial Flutter and Acute Decompensated Heart Failure

Abstract

Background: Guidelines recommend initial rate control in haemodynamically stable patients with atrial fibrillation (AF) or atrial flutter (AFL) and acute decompensated heart failure (ADHF). However, patients with persistent tachycardia or worsening heart failure despite medical therapy may require restoration of sinus rhythm. There is limited data on urgent rhythm control. We investigated the outcomes of patients managed with urgent DC cardioversion (DCCV) or ablation. Method: We retrospectively analysed patients presenting with AF or AFL and ADHF with LVEF≤40% who underwent inpatient TOE-guided DCCV or ablation. Primary endpoint was the one year composite outcome of mortality or rehospitalisation for stroke, myocardial infarction, arrhythmia or ADHF. Results: 79 patients were identified, including 33 with AF (32 DCCV, 1 ablation) and 46 with AFL (22 DCCV, 24 ablation). The primary endpoint occurred in 40% of patients. This was lower in the AFL-ablation subgroup compared to AFL-DCCV (22% vs 64%, P = 0.0056). At one year, mortality was 2.5%, 19% were rehospitalised for ADHF and 38% were rehospitalised for arrhythmia or ADHF. Sinus rhythm at 24 hours was 88.6%, with 42.9% clinical recurrence at one year. In the 63 patients with follow-up LV assessment (mean 5.3 months), 42.9% had LVEF > 50% and 74.6% had LVEF > 40% (P = <0.0001). Sinus rhythm at repeat LV assessment was associated with better LV function (LVEF > 40% in 82% vs 46.2%, P = 0.0138). Conclusion: Urgent DCCV or ablation for AF or AFL and ADHF had low mortality rates and rehospitalisation for heart failure. AFL-ablation had fewer events compared to AFL-DCCV. LV function improved substantially at follow-up.