Efficacy of Catheter Ablation of Atrial Fibrillation in Heart Failure with Preserved Ejection Fraction

BackgroundAtrial fibrillation (AF) in heart failure with preserved ejection fraction (HFpEF) has been associated with poor clinical outcomes. Catheter ablation has been shown to be an effective way to limit recurrence of AF and reduce stroke and mortality in patients with normal ventricular function and heart failure with reduced ejection fraction (HFrEF). Efficacy of catheter ablation in patients with HFpEF is less clear. We sought to evaluate clinical outcomes in the HFpEF population with ablation plus medical therapy as compared to medical therapy alone.MethodsWe conducted a single-center retrospective cohort review of 180 patients from 2007 to 2017. Inclusion criteria were patients who had a hospitalization with HFpEF and AF as hospital problems, EF≥50% and age ≥40. The ablation group includes all AF patients who underwent ablation and met inclusion criteria. The medical therapy cohort also met all the inclusion criteria and excluded patients with any ablations. Medical therapy included rate control, rhythm control or both. The primary outcome was AF at 1 year. Secondary outcomes were hospital admissions, stroke, and all-cause mortality.ResultsOut of 180 patients who met the inclusion criteria, 85 underwent catheter ablation and 95 were managed medically. More men underwent ablation vs. medical therapy (62.5% vs. 25.3%, p<0.001) and were also younger (67.9 vs. 75.5 years, p<0.001). The ablation group was more likely to be given rhythm control agents post ablation (41.1% vs. 4.2%, p<0.001) and the medical therapy group was more likely to be given rate control agents (62.3% vs. 85.0%, p<0.001). There was a significantly higher percentage of patients receiving anticoagulation in the ablation group, (83.5% vs. 68.4%, p=.018). AF occurrence at 1 year was lower for patients who underwent ablation (RR 0.29; 95% Cl 0.18 - 0.45). Risk of stroke was not significantly different at one year (HR 0.25; CI 0.06 - 1.12) however at 2 years was statistically lower in the ablation group (RR 0.22; CI 0.09 - 0.56). In both groups, 80% of strokes at 2 or more years were on anticoagulation. Risk of hospitalization at 1 year (RR 1.1; CI 0.85 - 1.41) and all-cause mortality at 1 year (RR 1.6; Cl 0.29 - 9.79) were similar.ConclusionIn patients with HFpEF and AF, catheter ablation along with medical therapy is an effective method of rhythm control and resulted in fewer strokes than medical management alone. Atrial fibrillation (AF) in heart failure with preserved ejection fraction (HFpEF) has been associated with poor clinical outcomes. Catheter ablation has been shown to be an effective way to limit recurrence of AF and reduce stroke and mortality in patients with normal ventricular function and heart failure with reduced ejection fraction (HFrEF). Efficacy of catheter ablation in patients with HFpEF is less clear. We sought to evaluate clinical outcomes in the HFpEF population with ablation plus medical therapy as compared to medical therapy alone. We conducted a single-center retrospective cohort review of 180 patients from 2007 to 2017. Inclusion criteria were patients who had a hospitalization with HFpEF and AF as hospital problems, EF≥50% and age ≥40. The ablation group includes all AF patients who underwent ablation and met inclusion criteria. The medical therapy cohort also met all the inclusion criteria and excluded patients with any ablations. Medical therapy included rate control, rhythm control or both. The primary outcome was AF at 1 year. Secondary outcomes were hospital admissions, stroke, and all-cause mortality. Out of 180 patients who met the inclusion criteria, 85 underwent catheter ablation and 95 were managed medically. More men underwent ablation vs. medical therapy (62.5% vs. 25.3%, p<0.001) and were also younger (67.9 vs. 75.5 years, p<0.001). The ablation group was more likely to be given rhythm control agents post ablation (41.1% vs. 4.2%, p<0.001) and the medical therapy group was more likely to be given rate control agents (62.3% vs. 85.0%, p<0.001). There was a significantly higher percentage of patients receiving anticoagulation in the ablation group, (83.5% vs. 68.4%, p=.018). AF occurrence at 1 year was lower for patients who underwent ablation (RR 0.29; 95% Cl 0.18 - 0.45). Risk of stroke was not significantly different at one year (HR 0.25; CI 0.06 - 1.12) however at 2 years was statistically lower in the ablation group (RR 0.22; CI 0.09 - 0.56). In both groups, 80% of strokes at 2 or more years were on anticoagulation. Risk of hospitalization at 1 year (RR 1.1; CI 0.85 - 1.41) and all-cause mortality at 1 year (RR 1.6; Cl 0.29 - 9.79) were similar. In patients with HFpEF and AF, catheter ablation along with medical therapy is an effective method of rhythm control and resulted in fewer strokes than medical management alone.