Catheter Ablation Of Atrial Fibrillation Research Articles

Concise guidelines of the European Cardiac Arrhythmias Society (ECAS) on "catheter ablation of atrial fibrillation": A prepublication of the methods in preparation of the final guidelines document.

Concise guidelines of the European Cardiac Arrhythmias Society (ECAS) on "catheter ablation of atrial fibrillation": A prepublication of the methods in preparation of the final guidelines document.

Successful catheter ablation of atrial tachycardia initiated with orthodromic capture of superior vena cava potentials.

Acase of successful catheter ablation of paroxysmal atrial fibrillation and atrial tachycardia is reported. After pulmonary vein isolation, atrial tachycardia was induced by the use of isoproterenol and burst pacing from the catheter in the right atrium. An attempt was made to create athree-dimensional (3D) map of the atrial tachycardia, but the atrial tachycardia was terminated in the middle of the mapping. The 3D map was insufficient but indicated that the superior vena cava was involved in the circuit. When the intracardiac electrograms were reviewed, it was found that the atrial tachycardia was initiated with orthodromic capture of superior vena cava potentials and it was considered that the atrial tachycardia involved the superior vena cava-right atrium junction. Accordingly, superior vena cava isolation was performed. After that, atrial fibrillation and atrial tachycardias were not induced by the use of isoproterenol and burst pacing. In this case, an intracardiac electrogram at the time of induction of the tachycardia was helpful for understanding the circuit of the tachycardia.

Safety and efficacy of anticoagulation therapy post atrial fibrillation ablation

Abstract Funding Acknowledgements None. Background Thromboembolic complications can be life-threatening during atrial fibrillation (AF) catheter ablation. The aim of our single center, retrospective study was to evaluate the safety and efficacy of continuous treatment using direct oral anticoagulants (DOACs) as an alternative to uninterrupted acenocoumarol for periprocedural anticoagulation. Purpose To record the safety and efficacy of the oral anticoagulants post atrial fibrillation ablation. Methods We studied 1999 patients undergoing AF catheter ablation between June 2013 and December 2021 in our center. All patients were assigned to take acenocoumarol (group 1, 194 patients) or DOACs (group 2, 1805 patients) for ≥2 months before the procedure. We compared thromboembolic and bleeding complications between the 2 groups. Results Our analysis showed no significant difference in major and minor complications between the 2 patient groups with the exception of the occurrence of groin hematoma with a clear superiority of DOACs (2.06%-0.5%, p<0.05). Specifically, 4 of 194 patients (2.06%) using uninterrupted acenocoumarol had a major complication (3 patients [1.55%] had transient ischemic attack resolved 8 hours later and 1 [0.52%] had pericardial tamponade, and 7 patients (3.61%) had minor complications (4 [2.06%] groin hematoma and 3 [1.55%] mild pericardial efussion). In group 2, 14 of 1805 patients (0.78%) had a major complication (11 patients had transient ischemic attack (0.61%) and 3 patients (0.17%) had pericardial tamponade). In the same group, 31 patients (1.72%) had a minor complication (3 patients [0.17%] presented with pseudoaneurysm or femoral arteriovenous fistula between the femoral artery and femoral vein, 19 [1.05%] with pericardial effusion <1 cm, and 9 [0.5%] groin hematoma). Conclusions DOACs and acenocoumarol have similar safety and effectiveness regarding thromboembolic complications prevention without increasing bleeding complications with the exception of the occurrence of groin hematoma with a clear superiority of DOACs.

Detection of Epicardial Connection Through Intercaval Bundle Involving Right Pulmonary Veins After Ipsilateral Circumferential Ablation by Intra-Atrial Activation Sequence Pacing From the Right Pulmonary Vein.

An epicardial connection (EC) through the intercaval bundle (EC-ICB) between the right pulmonary vein (RPV) and right atrium (RA) is one of the reasons for the need for carina ablation for PV isolation and may reduce the acute and chronic success of PV isolation. We evaluated the intra-atrial activation sequence during RPV pacing after failure of ipsilateral RPV isolation and sought to identify specific conduction patterns in the presence of EC-ICB. This study included 223 consecutive patients who underwent initial catheter ablation of atrial fibrillation. If the RPV was not isolated using circumferential ablation or reconnected during the waiting period, an exit map was created during mid-RPV carina pacing. If the earliest site on the exit map was the RA, the patient was classified into the EC-ICB group. The exit map, intra-atrial activation sequence, and RPV-high RA time were evaluated. First-pass isolation of the RPV was not achieved in 36 patients (16.1%), and 22 patients (9.9%) showed reconnection. Twelve and 28 patients were classified into the EC-ICB and non-EC-ICB groups, respectively, after excluding those with multiple ablation lesion sets or incomplete mapping. The intra-atrial activation sequence showed different patterns between the 2 groups. The RPV-high RA time was significantly shorter in the EC-ICB than in the non-EC-ICB group (69.2±15.2 versus 148.6±51.2 ms; P<0.001), and RPV-high RA time<89.0 ms was highly predictive of the existence of an EC-ICB (sensitivity, 91.7%; specificity, 89.3%). An EC-ICB can be effectively detected by intra-atrial sequencing during RPV pacing, and an RPV-high RA time of <89.0 ms was highly predictive.

Notched P‐wave on digital electrocardiogram predicts the recurrence of atrial fibrillation in patients who have undergone catheter ablation

AbstractBackgroundA notched P‐wave is associated with the occurrence of atrial fibrillation (AF). However, the association between a notched P‐wave and AF recurrence in patients who have undergone a catheter ablation for AF is unclear.MethodsWe enrolled 100 subjects who underwent catheter ablation for AF (paroxysmal AF: 60 cases; persistent AF: 40 cases). Twelve‐lead electrocardiography (ECG) was conducted, and the peak‐to‐peak distance in the M shape was calculated automatically using a 12‐lead ECG analysis system. A notched P‐wave was defined as a P‐wave with an M‐shape and a peak‐to‐peak distance of ≥20 ms in lead II. We compared the recurrence of AF in the patients with notched P‐wave and the others.ResultsThe mean follow‐up period was 12 ± 8 months, and a recurrence of AF was observed in 28 patients. The recurrence of AF in the notched P‐wave group was significantly higher than that in the controls (log rank 5.14, p = .023). A notched P‐wave was a significant predictor of the recurrence of AF after adjustment for age, gender, history of heart failure, history of catheter ablation, persistent AF, use of antiarrhythmic drugs, and the left atrial volume index (hazard ratio 2.470, 95% confidence interval 1.065–5.728, p = .035).ConclusionsAutomatically identified notched P‐waves with peak‐to‐peak distance ≥20 ms were associated with AF recurrence in patients who had undergone catheter ablation.

2023 Cardiac Society of Australia and New Zealand Expert Position Statement on Catheter and Surgical Ablation for Atrial Fibrillation

Catheter ablation for atrial fibrillation (AF) has increased exponentially in many developed countries, including Australia and New Zealand. This Expert Position Statement on Catheter and Surgical Ablation for Atrial Fibrillation from the Cardiac Society of Australia and New Zealand (CSANZ) recognises healthcare factors, expertise and expenditure relevant to the Australian and New Zealand healthcare environments including considerations of potential implications for First Nations Peoples. The statement is cognisant of international advice but tailored to local conditions and populations, and is intended to be used by electrophysiologists, cardiologists and general physicians across all disciplines caring for patients with AF. They are also intended to provide guidance to healthcare facilities seeking to establish or maintain catheter ablation for AF.

Catheter ablation for atrial fibrillation in heart failure with reduced ejection fraction patients: A meta-analysis

The optimal treatment for atrial fibrillation (AF) in patients with heart failure with reduced ejection fraction (HFrEF) remains unsettled. To assess the efficacy of catheter ablation (CA) and medical therapy compared to medical therapy alone in patients with AF and HFrEF. We performed a systematic review of randomized controlled trials (RCTs) comparing CA versus guideline-directed medical therapy for AF in patients with HFrEF (left ventricular ejection fraction (LVEF) ≤40%). We systematically searched PubMed, Embase, and Cochrane for eligible trials. A random-effects model was used to calculate the risk ratios (RRs) and mean differences (MDs), with 95% confidence intervals (CIs). Six RCTs comprising 1,055 patients were included, of whom 530 (50.2%) were randomized to CA. Compared with medical therapy, CA was associated with a significant reduction in heart failure (HF) hospitalization (RR 0.57; 95% CI 0.45-0.72; p<0.01), cardiovascular mortality (RR 0.46; 95% CI 0.31-0.70; p<0.01), all-cause mortality (RR 0.53; 95% CI 0.36-0.78; p<0.01), and AF burden (MD -29.8%; 95% CI -43.73,-15.90; p<0.01). Also, there was a significant improvement in LVEF (MD 3.8%; 95% CI 1.6,6.0; p<0.01) and quality of life (Minnesota living with HF questionnaire; MD -4.92 points; 95% CI -8.61,-1.22; p<0.01) in the ablation group. In this meta-analysis of RCTs of patients with AF and HFrEF, CA was associated with a reduction in HF hospitalization and cardiovascular and all-cause mortality, as well as a significant improvement of LVEF and quality of life.

Predictors of systolic function recovery after atrial fibrillation ablation in heart failure patients

Introduction and Objectives: Atrial fibrillation (AF) and heart failure (HF) often coexist. AF catheter ablation improves left ventricular ejection fraction (LVEF), but its impact varies between patients. We aimed to identify predictors of LVEF improvement in HF patients with impaired LVEF undergoing AF ablation.Methods: We conducted a retrospective single-center study in HF patients with LVEF <50% undergoing AF catheter ablation between May 2016 and May 2022. The primary endpoint was the LVEF recovery rate (‘responders’). Secondary endpoints were one-year safety and effectiveness. We also aimed to validate a prediction model for LVEF recovery.Results: The study included 100 patients (79% male, median age 60 years, 70% with probable tachycardia-induced cardiomyopathy [TIC], mean LVEF 37%, 29% with paroxysmal AF). After a median follow-up of 12 months after catheter ablation, LVEF improved significantly (36±10% vs. 53±10%, p<0.001), with an 82% responder rate. A suspected diagnosis of TIC (OR 4.916 [95% CI 1.166-20.732], p=0.030), shorter QRS duration (OR 0.969 [95% CI 0.945-0.994], p=0.015), and smaller left ventricle (OR 0.893 [95% CI 0.799-0.999], p=0.049) were independently associated with LVEF improvement. Freedom from any documented atrial arrhythmia was 86% (64% under antiarrhythmic drugs), and the rate of adverse events was 2%. The prediction model had a good discriminative performance (AUC 0.814 [95% CI 0.681-0.947]).Conclusion: In AF patients with HF and impaired LVEF, suspected TIC, shorter QRS duration, and smaller LV diameter were associated with LVEF recovery following AF catheter ablation.

A-29 | Impact of Frailty in Patients Undergoing Catheter Ablation for Atrial Fibrillation: A Nationwide Readmission Analysis

A-29 | Impact of Frailty in Patients Undergoing Catheter Ablation for Atrial Fibrillation: A Nationwide Readmission Analysis

Rhythm vs Rate Control Strategy for Atrial Fibrillation: A Meta-Analysis of Randomized Controlled Trials.

Rhythm control, either with antiarrhythmic drugs or catheter ablation, and rate control strategies are the cornerstones of atrial fibrillation (AF) management. Despite the increasing role of rhythm control over the past few years, it remains inconclusive which strategy is superior in improving clinical outcomes. This study summarizes the total and time-varying evidence regarding the efficacy of rhythm- vs rate-control strategies in the management of AF. We systematically perused the MEDLINE, CENTRAL (Cochrane Central Register of Controlled Trials), and Web of Science databases for randomized controlled trials from inception to November 2023. We included studies that compared the efficacy of rhythm control (ie, antiarrhythmic drugs classes Ia, Ic, or III, AF catheter ablation, and electrical cardioversion) and rate control (ie, beta-blocker, digitalis, or calcium antagonist) strategies among patients with nonvalvular AF. The primary outcome was cardiovascular (CV) death, whereas secondary outcomes included all-cause death, stroke, hospitalization for heart failure (HF), sinus rhythm at the end of the follow-up, and rhythm control-related adverse events. A cumulative meta-analysis to assess temporal trends and a meta-regression analysis using the percentage of ablation use was performed. We identified 18 studies with a total of 17,536 patients (mean age: 68.6 ± 9.7 years, 37.9% females) and a mean follow-up of 28.5months. Of those, 31.9% had paroxysmal AF. A rhythm control strategy reduced CV death (HR: 0.78; 95%CI: 0.62-0.96), stroke (HR: 0.801; 95%CI: 0.643-0.998), and hospitalization for HF (HR: 0.80; 95%CI: 0.69-0.94) but not all-cause death (HR: 0.86; 95%CI: 0.73-1.02) compared with a rate control strategy. This benefit was driven by contemporary studies, whereas more ablation use within the rhythm control arm was associated with improved outcomes, except stroke. In patients with AF, a contemporary rhythm control strategy leads to reduced CV mortality, HF events, and stroke compared with a rate control strategy.

Bilirubin Elevation During Hospitalization Post Radiofrequency Catheter Ablation of Persistent Atrial Fibrillation: Variation Trend, Related Factors, and Relevance to 1-Year Recurrence

Bilirubin Elevation During Hospitalization Post Radiofrequency Catheter Ablation of Persistent Atrial Fibrillation: Variation Trend, Related Factors, and Relevance to 1-Year Recurrence

Sex-based differences and risk of recurrence in patients with atrial fibrillation undergoing pulmonary vein isolation

IntroductionStudies suggest increased likelihood of atrial fibrillation (AF) recurrence after catheter ablation (CA) in women than in men, indicating that sex may be an independent risk factor for recurrence. Nevertheless, the influence of sex on AF recurrence and underlying mechanisms remains unclear. MethodsRetrospective, single-centre study including patients undergoing AF CA between 2017 and 2021. Late recurrence (LR) was defined as AF recurrence ≥90 days after ablation, whereas early recurrence (ER) occurred within 90 days. Results656 patients (32% women) were included, with a median follow-up period of 26 months. Compared to men, women undergoing CA were older, had higher body mass indexes, and had higher rates of hypertension, thyroid dysfunction, and valvular disease. Women also had increased LR risk after CA (HR 1.76, 95% CI [1.19, 2.59]). A time-split multivariable analysis at one year of follow-up showed no difference in LR risk during the first 12 months after CA (HR 1.19, 95% CI [0.73, 1.94]); however, LR risk increased in women (HR 2.90, 95% CI [1.68, 5.01]) after 12 months. In a sex-stratified analysis, coronary calcium score (CCS) >100 was associated with increased LR risk in men (HR 1.81, 95% CI [1.06, 3.08]), but not in women. Cardiac adipose tissue volume (CATV) was not associated with increased LR risk. ConclusionsFewer women underwent CA than men and LR was more frequent in women, particularly one year after the procedure. CCS was associated with increased LR risk in men.

Prevalence of left atrial appendage thrombus and spontaneous echo contrast on transesophageal echocardiography in patients scheduled for pulmonary vein isolation.

To avoid causing a thromboembolic event in patients undergoing catheter ablation for atrial fibrillation (AF), patients are treated with oral anticoagulants (OAC) prior to the procedure. Despite being on anticoagulants, some patients develop a left atrial appendage thrombus (LAAT). To exclude the presence of LAAT, transesophageal ultrasound (TEE) is performed in all patients prior to the procedure. We hypothesized continuous treatment with anticoagulants would result in a low prevalence of LAAT, in patients with low CHA2DS2-VASc score. Medical records of consecutive patients planned to undergo AF ablation at Lund University Hospital during the years 2018-2020 were reviewed retrospectively. Examination protocols from transesophageal and transthoracic echocardiography were examined for LAAT and spontaneous echo contrast (SEC). Patients with LAAT and SEC were compared to patients without using Mann-Whitney U-test and Pearson Chi-squared analysis to test for correlation. Of 553 patients, three patients (0.54%) had LAAT, and 18 (3.25%) had spontaneous contrast (SEC). Patients with LAAT or SEC had a higher CHA2DS2-VASc score, more often presented in AF at TEE and less often had a normal sized left atrium. There is a low prevalence of LAAT and SEC in patients with AF scheduled for pulmonary vein isolation. Patients with SEC or LAAT tend to have paroxysmal AF less often and more often presented in AF at admission. No patients with CHA2DS2-VASc 0, paroxysmal AF, normal sized left atrium and sinus rhythm at TEE were found to have LAAT or SEC.

How to demonstrate factors associated with peri‐esophageal vagal nerve injury during catheter ablation for atrial fibrillation

How to demonstrate factors associated with peri‐esophageal vagal nerve injury during catheter ablation for atrial fibrillation

Associations of the fibrosis‐4 index with left atrial low‐voltage areas and arrhythmia recurrence after catheter ablation: cardio‐hepatic interaction in patients with atrial fibrillation

AbstractBackgroundThe relationship between liver fibrosis and left atrial (LA) remodeling in atrial fibrillation (AF) remains uncertain. We examined the associations between the fibrosis‐4 (FIB4) index, an indicator of liver fibrosis, and both LA low‐voltage areas (LVAs) on electroanatomic mapping and AF recurrence postablation.MethodsWe recruited 343 patients who underwent radiofrequency catheter ablation (RFCA) or cryoballoon ablation (CBA) for AF. First, the association between the FIB4 index and LA LVAs (&lt;0.5 mV) was evaluated in RFCA using electroanatomic mapping (n = 214). Next, the utility of a FIB4 index ≥1.3, recommended cut‐off value of liver fibrosis, was verified to assess the risk for AF recurrence in CBA without additional LVA ablation (n = 129).ResultsPatients with a FIB4 index ≥1.3 had a higher prevalence of LA LVAs (&gt;5 cm2) compared to those without. Additionally, the quantitative size of LVAs showed a positive correlation with the FIB4 index (R = .642, p &lt; .001). In multivariate logistic models, a FIB4 index ≥1.3 was related to the presence of LVAs after adjusting for LA diameter, right atrial end‐systolic area, and nonparoxysmal AF (odds ratio 2.508; p = 0.039). In CBA, AF recurrence rate was 13.1% during 3–12 months postablation. In multivariate Cox models, a FIB4 index ≥1.3 was an important predictor of AF recurrence (hazard ratio 3.796; p = .037), suggesting that LVAs might be associated with AF recurrence after CBA.ConclusionThe FIB4 index was a novel predictor of the existence of LA LVAs on electroanatomic mapping and AF recurrence after CBA.

Long-term outcomes after hospitalization for atrial fibrillation or flutter.

Atrial fibrillation (AF) and flutter are common causes of hospitalizations but contemporary long-term outcomes following these episodes are uncertain. This study assessed outcomes up to 10 years after an acute AF or flutter hospitalization. Patients hospitalized acutely with a primary diagnosis of AF or flutter from 2008-17 from all public and most private hospitals in Australia and New Zealand were included. Kaplan-Meier methods and flexible parametric survival modelling were used to estimate survival and loss in life expectancy, respectively. Competing risk model accounting for death was used when estimating incidence of non-fatal outcomes. A total of 260 492 adults (mean age 70.5 ± 14.4 years, 49.6% female) were followed up for 1 068 009 person-years (PY), during which 69 167 died (incidence rate 6.5/100 PY) with 91.2% survival at 1 year, 72.7% at 5 years, and 55.2% at 10 years. Estimated loss in life expectancy was 2.6 years, or 16.8% of expected life expectancy. Re-hospitalizations for heart failure (2.9/100 PY), stroke (1.7/100 PY), and myocardial infarction (1.1/100 PY) were common with respective cumulative incidences of 16.8%, 11.0%, and 7.1% by 10 years. Re-hospitalization for AF or flutter occurred in 21.3% by 1 year, 35.3% by 5 years, and 41.2% by 10 years (11.6/100 PY). The cumulative incidence of patients undergoing catheter ablation of AF was 6.5% at 10 years (1.2/100 PY). Patients hospitalized for AF or flutter had high death rates with an average 2.6-year loss in life expectancy. Moreover, re-hospitalizations for AF or flutter and related outcomes such as heart failure and stroke were common with catheter ablation used infrequently for treatment, which warrant further actions.

Epicardial Atrial Fat at Cardiac Magnetic Resonance Imaging and AF Recurrence after Transcatheter Ablation

The relationship between epicardial adipose tissue (EAT) and atrial fibrillation (AF) has gained interest in recent years. The previous literature on the topic presents great heterogeneity, focusing especially on computed tomography imaging. The aim of the present study is to determine whether an increased volume of left atrial (LA) EAT evaluated at routine pre-procedural cardiac magnetic resonance imaging (MRI) relates to AF recurrences after catheter ablation. A total of 50 patients undergoing AF cryoballoon ablation and pre-procedural cardiac MRI allowing quantification of LA EAT were enrolled. In one patient, the segmentation of LA EAT could not be achieved. After a median follow-up of 16.0 months, AF recurrences occurred in 17 patients (34%). The absolute volume of EAT was not different in patients with and without AF recurrences (10.35 mL vs. 10.29 mL; p-value = 0.963), whereas the volume of EAT indexed on the LA volume (EATi) was lower, albeit non-statistically significant, in patients free from arrhythmias (12.77% vs. 14.06%; p-value = 0.467). The receiver operating characteristic curve testing the ability of LA EATi to predict AF recurrence after catheter ablation showed sub-optimal performance (AUC: 0.588). The finest identified cut-off of LA EATi was 10.65%, achieving a sensitivity of 0.5, a specificity of 0.82, a positive predictive value of 0.59 and a negative predictive value of 0.76. Patients with values of LA EATi lower than 10.65% showed greater survival, free from arrhythmias, than patients with values above this cut-off (84% vs. 48%; p-value = 0.04). In conclusion, EAT volume indexed on the LA volume evaluated at cardiac MRI emerges as a possible independent predictor of arrhythmia recurrence after AF cryoballoon ablation. Nevertheless, prospective studies are needed to confirm this finding and eventually sustain routine EAT evaluation in the management of patients undergoing AF catheter ablation.

Efficacy of catheter ablation for atrial fibrillation in heart failure: a meta-analysis of randomized controlled trials.

The study aims to evaluate whether rhythm control by catheter ablation is superior to medical therapy for the patients with atrial fibrillation (AF) and heart failure (HF). The literatures were searched by using PubMed, Cochrane Library, Embase, and Web of Science databases up to 12 October 2023. The randomized controlled trials (RCTs) comparing rhythm control using catheter ablation vs. medical therapy in AF patients with HF were pooled. The primary outcomes included all-cause mortality, HF re-hospitalization, and stroke, and the secondary outcomes included left ventricular ejection fraction (LVEF), atrial tachyarrythmia recurrence, quality of life (Minnesota Living with Heart Failure Questionnaire score, MLHFQ score), 6min walking distance (6MWD), the level of N-terminal B-type natriuretic peptide precursor (NT-proBNP), and adverse events. Nine RCTs involving in 2293 patients met the inclusion criteria. Compared with medical therapy, catheter ablation reduced all-cause mortality [10.07% (121/1201) vs. 15.26% (175/1147), risk ratio (RR):0.60, 95% confidence interval (CI): 0.48-0.74, P<0.00001, I2=0%] and the rate of HF re-hospitalization (RR: 0.65, P=0.02, 95% CI: 0.45 to 0.94, I2=74%), but had no obvious difference in incidence of stroke (RR: 0.67, P=0.27, 95% CI: 0.32 to 1.38, I2=0%). Catheter ablation enhanced LVEF [mean difference (MD), 6.26%, P<0.00001, I2=89%], reduced AT recurrence (RR: 0.37, P<0.00001, 95% CI: 0.26 to 0.52, I2=89%), improved the quality of life (MLHFQ score) (MD: -6.83, P=0.003, I2=67%), elevated 6MWD (MD: 15.92, P=0.006, I2=76%), and diminished the level NT-proBNP (MD: -44.19, P<0.00001, I2=75%), but had no significant difference in adverse events [25.81% (310/1201) vs. 30.25% (347/1147), RR: 0.81, 95% CI: 0.65-1.01, P=0.06, I2=55%]. Catheter ablation as rhythm control strategy substantially enhances the survival rate, reduces HF re-hospitalization, increases the rate of sinus rhythm maintenance, improves the left ventricular function and the quality of life for AF patients with HF, and has similar safety, compared with medical therapy. The rhythm control by catheter ablation may be a better strategy for the AF patients with HF.

Adjunctive low-voltage area ablation for patients with atrial fibrillation: An updated meta-analysis of randomized controlled trials.

The efficacy and safety of adjunctive low-voltage area (LVA) ablation on outcomes of catheter ablation (CA) for atrial fibrillation (AF) remains uncertain. PubMed, Embase, Cochrane Library, and ClinicalTrials.gov were searched for randomized controlled trials (RCTs) comparing CA with versus without LVA ablation for patients with AF. Risk ratios (RR) with 95% confidence intervals (CI) were pooled with a random-effects model. Our primary endpoint was recurrence of atrial tachyarrhythmia (ATA), including AF, atrial flutter, or atrial tachycardia. We used R version 4.3.1 for all statistical analyses. Our meta-analysis included 10 RCTs encompassing 1780 patients, of whom 890 (50%) were randomized to LVA ablation. Adjunctive LVA ablation significantly reduced recurrence of ATA (RR 0.76; 95% CI 0.67-0.88; p < .01) and reduced the number of redo ablation procedures (RR 0.54; 95% CI 0.35-0.85; p < .01), as compared with conventional ablation. Among 691 (43%) patients with documented LVAs on baseline substrate mapping, adjunctive LVA ablation substantially reduced ATA recurrences (RR 0.57; 95% CI 0.38-0.86; p < .01). There was no significant difference between groups in terms of periprocedural adverse events (RR 0.78; 95% CI 0.39-1.56; p = .49). Adjunctive LVA ablation is an effective and safe strategy for reducing recurrences of ATA among patients who undergo CA for AF.

Atrial Fibrillation Ablation in Heart Failure With Reduced vs Preserved Ejection Fraction

Catheter ablation is associated with reduced heart failure (HF) hospitalization and death in select patients with atrial fibrillation (AF) and heart failure with reduced ejection fraction (HFrEF). However, the benefit in patients with HF with preserved ejection fraction (HFpEF) is uncertain. To investigate whether catheter ablation for AF is associated with reduced HF-related outcomes according to HF phenotype. A systematic search of MEDLINE, Embase, and Cochrane Central was conducted among studies published from inception to September 2023. Parallel-group randomized clinical trials (RCTs) comparing catheter ablation with conventional rate or rhythm control therapies in patients with HF, New York Heart Association functional class II or greater, and a history of paroxysmal or persistent AF were included. Pairs of independent reviewers screened 7531 titles and abstracts, of which 12 RCTs and 4 substudies met selection criteria. Data were abstracted in duplicate according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Pooled effect estimates were calculated using random-effects Mantel-Haenszel models. Interaction P values were used to test for subgroup differences. The primary outcome was HF events, defined as HF hospitalization, clinically significant worsening of HF, or unscheduled visits to a clinician for treatment intensification. Secondary outcomes included cardiovascular and all-cause mortality. A total of 12 RCTs with 2465 participants (mean [SD] age, 65.3 [9.7] years; 658 females [26.7%]) were included; there were 1552 participants with HFrEF and 913 participants with HFpEF. Compared with conventional rate or rhythm control, catheter ablation was associated with reduced risk of HF events in HFrEF (risk ratio [RR], 0.59; 95% CI, 0.48-0.72), while there was no benefit in patients with HFpEF (RR, 0.93; 95% CI, 0.65-1.32) (P for interaction = .03). Catheter ablation was associated with reduced risk of cardiovascular death compared with conventional therapies in HFrEF (RR, 0.49; 95% CI, 0.34-0.70) but a differential association was not detected in HFpEF (RR, 0.91; 95% CI, 0.46-1.79) (P for interaction = .12). Similarly, no difference in the association of catheter ablation with all-cause mortality was found between HFrEF (RR vs conventional therapies, 0.63; 95% CI, 0.47-0.86) and HFpEF (RR vs conventional therapies, 0.95; 95% CI, 0.39-2.30) groups (P for interaction = .39). This study found that catheter ablation for AF was associated with reduced risk of HF events in patients with HFrEF but had limited or no benefit in HFpEF. Results from ongoing trials may further elucidate the role of catheter ablation for AF in HFpEF.