Long-term follow-up after atrial fibrillation ablation in patients with impaired left ventricular systolic function: The importance of rhythm and rate control

doi:10.1016/j.hrthm.2013.12.031

Heart Rhythm

Volume 11, Issue 3, March 2014, Pages 344-351

https://doi.org/10.1016/j.hrthm.2013.12.031 Get rights and content

Background

Atrial fibrillation (AF) ablation is increasingly used in patients with reduced left ventricular ejection fraction (LVEF), but long-term outcomes are still unknown.

Objective

To assess the long-term effects of AF ablation in patients with systolic heart failure according to rhythm outcome.

Methods

We included 69 patients with LVEF ≤40%, referred for circumferential pulmonary vein isolation with or without additional substrate modification to our institution in 2006–2010. Follow-up included 7-day Holter electrocardiography and echocardiography at baseline and at 6, 12, and 24 months after ablation. A matched control group (n = 69) after AF ablation without heart failure was used for comparison.

Results

After 28 ± 11 months and 1.6 ± 0.7 ablation procedures, 45 (65%) patients were still in the stable sinus rhythm (SSR) group. LVEF increased from 33 ± 6% to 53 ± 11% (P < .001) in the SSR group and from 33 ± 5% to 38 ± 12% (P = .03) in patients with recurrences (atrial tachycardia/fibrillation group). While LVEF increase was similar in the 2 groups at 6 months (15 ± 12% vs 8 ± 11%; P = .2), further LVEF improvements were observed in the SSR group only. Adjustments for baseline characteristics revealed that the increase in LVEF at 6 months was associated with higher baseline heart rate and not with rhythm outcome. Heart rate did not change in either group after 6 months of follow-up. Complications and procedural data of the study group were similar to the control group.

Conclusion

In patients with heart failure undergoing AF ablation, there is an initial short-term LVEF improvement related to baseline heart rate. However, long-term LVEF improvement is associated with rhythm outcome.

Introduction

Heart failure and atrial fibrillation (AF) are both major public health burdens that often beget one another. Patients with reduced left ventricular ejection fraction (LVEF) have a high prevalence of AF associated with higher morbidity and mortality.¹ Previous studies showed no advantage of drug-based rhythm control over rate control in patients with AF.2, 3, 4 Although sinus rhythm is beneficial when maintained, its potential benefits may be offset by adverse effects of antiarrhythmic drugs.5, 6 This explains the great interest in nonpharmacological approaches to rhythm control. Catheter ablation of AF has been shown to be more effective than antiarrhythmic drugs and is being increasingly used for patients with heart failure. Several studies have reported similar short-term results of AF ablation in patients with and without heart failure.7, 8, 9, 10, 11, 12 In some of these cases though, especially in younger patients with nonischemic cardiomyopathies, recovery from tachycardia-induced cardiomyopathy may partially explain the initial LVEF improvement.7, 10, 12, 13

However, little is known about the long-term effects on LVEF and its relationship with rhythm outcome. We evaluated the long-term effects of rhythm outcome on LV function in patients with systolic heart failure who were prospectively followed up at our institution after AF ablation.

Section snippets

Study population

From 2065 consecutive patients referred to our institution in 2006–2010 for first-time catheter ablation of symptomatic, treatment-refractory AF, we identified 74 (4%) with LVEF ≤40% and clinical heart failure of New York Heart Association (NYHA) class ≥II. Five patients were excluded because of noncompliance with follow-up. All patients gave written informed consent. Table 1 lists the characteristics of the patients. Patients were divided into 2 groups: (1) the stable sinus rhythm (SSR) group

Study population

Patient data are summarized in Table 1. Coronary artery disease (CAD) defined as coronary artery obstruction >50% was present in 26 (38%) patients, 10 (14%) with prior myocardial infarction. Sixteen patients had prior interventional (n = 13, 19%) or surgical (n = 3, 4%) revascularization. Nine patients with regional wall motion abnormalities on echocardiography (4 in the SSR group and 5 in the ATF group; P = .26) showed no improvement in heart failure symptoms after AF ablation.

Baseline heart

Major findings

We studied the changes in LV function after AF ablation in patients with systolic heart failure stratified by rhythm outcome. Systematic long-term follow-up data including 7-day-Holter ECG recordings allowed us to carefully assess the effect of changes in the heart rate on LVEF. We found that the initial LVEF improvement at 6 months after ablation in successfully treated patients may be partially attributed to a better heart rate control. However, further LVEF improvements to normalization were

Conclusions

Catheter ablation in patients with AF and impaired LV function is associated with an initial short-term LVEF improvement related to baseline heart rate. However, long-term LVEF improvements are mainly associated with rhythm control.

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Cited by (57)

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines
2024, Journal of the American College of Cardiology
The “2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation” provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.
A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.
Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the “2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation” and the “2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation” have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
Clinical Characterization of Arrhythmia-Induced Cardiomyopathy in Patients With Tachyarrhythmia and Idiopathic Heart Failure
2024, JACC: Clinical Electrophysiology
Arrhythmia-induced cardiomyopathy (AIC) is a known entity, but prospective evidence for its characterization is limited.
This study aimed to: 1) determine the relative frequency of the pure form of AIC in the clinically relevant cohort of patients with newly diagnosed, otherwise unexplained left ventricular systolic dysfunction (LVSD) and tachyarrhythmia; 2) assess the time to recovery from LVSD; and 3) identify parameters for an early diagnosis of AIC.
Patients were prospectively included, underwent effective rhythm restoration, and were followed-up at 2, 4, and 6 months to evaluate clinical characteristics, biomarkers, and cardiac imaging including cardiac magnetic resonance imaging. Patients with recurred arrhythmia were excluded from analysis.
41 of 50 patients were diagnosed with AIC 6 months after rhythm restoration. Left ventricular (LV) ejection fraction increased 2 months after rhythm restoration from 35.4% ± 8.2% to 52.7% ± 8.0% in AIC patients vs 37.0% ± 9.5% to 43.3% ± 7.0% in non-AIC patients. From month 2 to 6, LV ejection fraction continued to increase in AIC patients (57.2% ± 6.1%; P < 0.001) but remained stable in non-AIC patients (44.0% ± 7.8%; P = 0.628). Multivariable logistic regression analysis revealed that lower LV end-diastolic diameter at baseline could be used for early diagnosis of AIC, whereas biomarkers and other morphological or functional parameters, including late LV gadolinium enhancement, did not show suitability for early diagnosis.
We observed a high prevalence of AIC in patients with otherwise unexplained LVSD and concomitant tachyarrhythmia, suggesting that this condition may be underdiagnosed in clinical practice. Most patients recovered fast, within months, from LVSD. A low initial LV end-diastolic diameter may constitute an early marker for diagnosis of AIC.
Clinical Outcomes of Decompensated Heart Failure With Reduced Ejection Fraction Admissions With or Without Atrial Fibrillation and Atrial Flutter
2024, Current Problems in Cardiology
The aim of our retrospective study is to determine the influence of co-morbid atrial fibrillation or flutter (AF) on decompensated congestive heart failure (CHF) admissions using data from the 2020 nationwide inpatient sample. We identified 76,835 adults admitted nonelectively with decompensated CHF. After multivariate adjustment, we found decompensated heart failure with reduced ejection fraction (HFrEF) admissions with AF had 37% higher odds of in-hospital mortality, (OR 1.38 [95% CI 1.1-1.72] P < 0.01), 33% higher odds for mechanical ventilation (MV) (OR 1.33 [95% CI 1.14-1.55] P < 0.01), 39% higher odds of early MV (OR 1.39 [95% CI 1.16-1.66] P < 0.01), 54% higher odds of cardiogenic shock (OR 1.54 [95% CI 1.29-1.84] P < 0.01), 61% increased odds of mechanical circulatory support (MCS) requirement (OR 1.61 [95% CI 1.12-2.31] P < 0.02), significantly higher odds of acute renal failure (AKI) necessitating dialysis (OR 2.20 [95% CI 1.39-2.48] P < 0.01), 1-day increase in mean length of stay (LOS) (6.7 vs 5.7 days, adjusted difference: 0.99, P < 0.01), $13,281 increase in total hospitalization charges ($84,316 vs $74,279, adjusted difference: $13,281, P < 0.05) compared to the non-AF cohort. Moreover, we found decompensated heart failure with preserved ejection fraction (HFpEF) admissions with AF had a 23% increased odds of MV (OR 1.23 [95% CI 1.01-1.50] P < 0.01), 24% higher odds of early MV (OR 1.24 [95% CI 1.00-1.53] P < 0.01), 0.36 days increase in mean LOS (5.5 vs 5.2 days, adjusted difference: 0.36, P = < 0.01), but no significant difference in in-hospital mortality (OR 1.23 [95% CI 0.86-1.75] P = 0.25), cardiogenic shock (OR 1.75 [95% CI 0.96-3.19] P < 0.07), dialysis-dependent AKI (OR 0.46 [95% CI 0.18-1.17] P < 0.10), or mean total hospitalization charges ($52,086 vs $47,990, adjusted difference: $5584, P = 0.06) compared to the non-AF cohort.
Left atrial appendage peak flow velocity predicts improvement in mitral regurgitation after atrial fibrillation ablation
2024, Journal of Cardiology
Mitral regurgitation (MR) is associated with an increased risk of developing atrial fibrillation (AF) and high AF recurrence ratio after ablation. Left atrial appendage (LAA) is involved in left atrium (LA) pressure modulation and LAA peak flow velocity (LAAV) is validated as an indicator of LA contractile and reservoir function. LA function is related to the MR pathology, but the relationship between LAAV and improvement in MR after ablation remains unknown.
The present study included AF patients with moderate or severe MR from the Osaka Rosai Atrial Fibrillation ablation (ORAF) registry. We evaluated MR severity one-year post-ablation and assigned the patients based on MR improvement (at least a one-grade improvement in MR over one year) and investigated the impact of the relevant factors, including LAAV, on MR improvement.
This study population included a total of 289 patients [paroxysmal AF (PAF), 112 patients; persistent AF (PerAF), 177 patients]. Kaplan-Meier analysis demonstrated that the patients with MR improvement had a significantly lower risk of late arrhythmia recurrence than those without (log-rank p < 0.001). MR improvement was observed in 56.3 % (63/112) of PAF patients and 55.4 % (98/177) of PerAF patients. Multiple regression analysis showed that LAAV was an independent and significant determinant of MR improvement post-ablation in both PAF and PerAF patients (p = 0.037 and p = 0.018, respectively), in addition to age and hemoglobin in PerAF patients (p = 0.045 and p = 0.048, respectively).
LAAV can predict an improvement in MR after catheter ablation in both PAF and PerAF patients.
Impact of catheter ablation for atrial fibrillation in patients with heart failure and left ventricular systolic dysfunction
2021, Revista Portuguesa de Cardiologia
Catheter ablation has been shown to improve left ventricular (LV) ejection fraction (LVEF) in patients with atrial fibrillation (AF) and heart failure (HF). Our aim was to assess the impact of AF ablation on the outcome of patients with HF and LV systolic dysfunction.
We performed a retrospective observational cohort study of all patients with HF and LVEF <50% and with no apparent cause for systolic dysfunction other than AF who underwent catheter ablation in a tertiary referral center between July 2016 and November 2018. The primary endpoint was a ≥5% improvement in LVEF. Secondary endpoints included improvement in New York Heart Association (NYHA) class and reduction in LV end-diastolic diameter (LVEDD) and left atrial diameter (LAD).
Of 153 patients who underwent AF ablation in this period, 22 (77% male, median age 61 [IQR 54-64] years) fulfilled the inclusion criteria. Median follow-up was 11.1 months (IQR 6.1-19.0). After ablation, median LVEF increased from 40% (IQR 33-41) to 58% (IQR 55-62) (p<0.01), mean NYHA class improved from 2.35±0.49 to 1.3±0.47 (p<0.001), and median LAD and LVEDD decreased from 48.0 (IQR 43.5-51.5) mm to 44 (IQR 40-49) mm (p<0.01) and from 61.0 (IQR 54.0-64.8) mm to 55.0 (52.2-58.0) mm (p<0.01), respectively.
In patients with HF and LV systolic dysfunction, AF ablation is associated not only with improved functional status but also with favorable structural remodeling, including improvement in LVEF and decreases in LAD and LVEDD.
A ablação por cateter está associada a uma melhoria da fração de ejeção ventricular esquerda (FEVE) em doentes com insuficiência cardíaca (IC) e fibrilhação auricular(FA). O objetivo deste trabalho foi avaliar o impacto da ablação de FA em doentes com IC e disfunção sistólica do ventrículo esquerdo.
Estudo observacional retrospetivo dos doentes com IC e FEVE < 50% sem causa aparente para a disfunção ventricular para além da FA, submetidos a ablação num centro de referência entre julho/2016-novembro/2018. O endpoint primário foi uma melhoria da FEVE ≥ 5%. Os endpoints secundários foram a melhoria na classe funcional da New York Heart Association (NYHA) e a redução do diâmetro auricular esquerdo (DAE) e do diâmetro telediastólico do ventrículo esquerdo (DTDVE).
Dos 153 doentes submetidos a ablação de FA neste período, 22 foram incluídos (77% do género masculino, idade mediada de 61 anos [IQR 54-64]). O tempo de seguimento mediano foi de 11, 1meses (IQR 6,1-19,0). Após a ablação, a mediana da FEVE passou de 40% (IQR 33-41) para 58% (55-62), P < 0,01, enqanto a classe de NYHA passou de 2,35 ± 0,49 para 1,3 ± 0,47, P < 0,001, o DAE de 48,0 (IQR 43,5-51,5) mm para 44 (IQR 40-49)mm (P < 0,01) e o DTDVE de 61,0 (IQR 54,0-64,8)mm para 55,0 (52,2-58,0, P < 0,01).
Em doentes com IC e disfunção sistólica do ventrículo esquerdo, a ablação de FA associa-se a uma melhoria da classe funcional e a uma remodelagem estrutural favorável, incluindo melhoria da FEVE e diminuição do DAE e DTDVE.
Atrial Fibrillation Burden and Clinical Outcomes in Heart Failure: The CASTLE-AF Trial
2021, JACC: Clinical Electrophysiology
This subanalysis of the CASTLE-AF (Catheter Ablation vs. Standard Conventional Treatment in Patients With LV Dysfunction and AF) trial aimed to address the association between atrial fibrillation (AF) recurrence, AF burden, and hard clinical outcomes in heart failure (HF) patients with AF.
The CASTLE-AF trial demonstrated the benefit of CA compared to pharmacological treatment in decreasing mortality and CV hospitalizations in patients with AF and HFrEF. However, the impact of AF recurrence and AF burden after ablation on long-term treatment benefit remains unknown.
The CASTLE-AF protocol randomized 363 patients with coexisting HF and AF in a multicenter prospective controlled fashion to catheter ablation (n = 179) versus pharmacological therapy (n = 184). Two hundred eighty patients were included in this subanalysis (as-treated), 128 of them underwent ablation and 152 received pharmacological treatment. All patients had implanted dual chamber or biventricular implantable defibrillators with activated home monitoring capabilities. The individual AF burden was calculated as the percentage of the atrial arrhythmia time per day.
AF burden at baseline was not predictive of the primary endpoint (p = 0.473) or all-cause mortality (p = 0.446). AF recurrence (defined as any episode >30 s) did not show any relationship with the primary endpoints of mortality and occurrence of HF, irrespective of the treatment arm. An AF burden below 50% after 6 months of catheter ablation, was associated with a significant decrease in primary composite outcome (hazard ratio [HR]: 0.33; 95% confidence interval [CI]: 0.15 to 0.71; p = 0.014) and all-cause mortality (HR: 0.23; 95% CI: 0.07 to 0.71; p = 0.031). The risk of the primary endpoint or mortality was directly related to a low (<50%) or high (≥50%) AF burden at 6 months post-ablation.
AF burden at 6 months was predictive of hard clinical outcomes in HF patients with AF. The first recurrent atrial tachyarrhythmia episode >30 s after ablation was not associated with improvement in mortality and hospitalization for HF. (Catheter Ablation vs. Standard Conventional Treatment in Patients With LV Dysfunction and AF [CASTLE-AF]; NCT00643188)

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: Dr Rolf, Dr Sommer, and Dr Arya have received modest lecture honoraria and congress sponsoring from St Jude Medical, Biosense Webster, and Biotronik. Dr Hindricks has received modest lecture honoraria from St Jude Medical, Biotronik, Medtronic, and Biosense Webster and is a member of the St Jude Medical and Biosense Webster advisory board. Dr Piorkowski has received modest lecture honoraria from St Jude Medical and Biotronik and is a member of the St Jude Medical advisory board.

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Long-term follow-up after atrial fibrillation ablation in patients with impaired left ventricular systolic function: The importance of rhythm and rate control

Background

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Study population

Study population

Major findings

Conclusions

J Am Coll Cardiol

J Card Fail

Heart Rhythm

Am J Med

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Temporal relations of atrial fibrillation and congestive heart failure and their joint influence on mortality: the Framingham Heart Study

Circulation

A comparison of rate control and rhythm control in patients with atrial fibrillation

N Engl J Med

A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation

N Engl J Med