Early vs delayed ablation for atrial fibrillation in heart failure with reduced ejection fraction

Background

Although the role of diagnosis to ablation time (DAT) has been observed to be associated with superior outcomes in patients with atrial fibrillation (AF), its role in patients with concomitant heart failure with reduced ejection fraction (HFrEF) remains unclear. In our study, we sought to investigate the role of DAT in patients with coexisting AF and HFrEF from a large, real-world dataset.

Purpose

To assess the impact of DAT <1 year vs DAT ≥1 year in patients with concomitant AF and HFrEF on clinical outcomes.

Methods

We analyzed the TriNetX research network for patients ≥18 years of age with a diagnosis of AF and HFrEF who underwent catheter ablation between January 1, 2010, and Dec 31, 2019. We used DAT of 1 year after the diagnosis of AF and HFrEF to categorize patients into 2 cohorts:

(a): Early catheter ablation: DAT of < 1 year

(b): Delayed catheter ablation: DAT > 1 year

Patients were matched using 1:1 propensity scores, which resulted in 1,629 in each patient cohort. Follow up data were evaluated for a period of 5 years following a 3-month blanking period after catheter ablation. The primary outcomes of our study were: (a) AF recurrence, (b) need for cardioversion, (c) repeat ablation for atrial arrhythmias and (d) use of antiarrhythmic drugs (AADs). AF recurrence was defined as a composite of cardioversion, repeat ablation and AAD use. Secondary outcomes included: (a) Heart failure exacerbation, (b) stroke (c) all cause rehospitalization (d) all-cause mortality.

Results

In the patients with concomitant AF and HFrEF, earlier ablation (as defined by DAT of <1 year) was associated with significantly lower risk of AF recurrence (HR 0.7; 95% CI: 0.63–0.77; p < 0.001), cardioversion (HR 0.59; 95% CI: 0.51–0.67; p < 0.001), repeat ablation (HR 0.70; 95% CI: 0.59–0.82; p <0.001), AAD use (HR 0.64; 95% CI: 0.44–0.94; p: 0.02), and all cause rehospitalization (HR 0.81; 95% CI: 0.74–0.89; p <0.001).

In our study, we did not observe a statistically significant reduction in the risk of stroke (HR 1.14; 95% CI: 0.87–1.5; p = 0.32), heart failure exacerbation (HR 0.94; 95% CI: 0.86–1.04; p = 0.26), and all-cause mortality (HR 0.93; 95% CI: 0.75–1.15; p = 0.53) when comparing early vs delayed ablation.

Conclusion

Catheter ablation within 1 year of diagnosis of AF in patients with HFrEF was associated with a decreased risk of AF recurrence, need for cardioversion, AAD use, redo ablations and rehospitalizations. Our findings support an earlier referral for catheter ablation for patients with coexisting AF and HFrEF.Figure 1:AF recurrence and cardioversionFigure 2:Redo ablation and use of AADs