Impact of HFrEF etiology on outcomes after pulmonary vein isolation for atrial fibrillation
A A Boehmer, M M Zylla, S Feickert, K Dyrda, H A K Hillmann, D Stangl, J Yogarajah, M Lemoine, M Rothe, A K Kahle, K Iliodromitis, R Wakili, J Andrade, S Nattel, J EhrlichAbstract
Background
Catheter ablation-based rhythm control has become a key therapeutic strategy in patients with atrial fibrillation (AF) and heart failure with reduced ejection fraction (HFrEF). However, whether the underlying cardiomyopathy etiology influences ablation outcomes remains uncertain.
Purpose
To evaluate the impact of HFrEF etiology on rhythm outcomes and safety following pulmonary vein isolation (PVI) in patients with AF and HFrEF (LVEF ≤40%)
Methods
In this retrospective, international multicenter study, patients with paroxysmal or persistent AF and HFrEF undergoing first-time single-shot PVI-only (pulsed field or cryoballoon ablation) between 2012 and 2025 were included. Patients were stratified by HFrEF etiology: ischemic cardiomyopathy (ICM), non-ischemic dilated cardiomyopathy (NI-DCM), or AF-mediated cardiomyopathy (AF-CM). The primary efficacy endpoint was the first documented recurrence of any atrial tachyarrhythmia after a 3-month blanking period. Safety endpoints comprised all-cause death, stroke/transient ischemic attack, and procedure-related adverse events.
Results
A total of 694 patients from 12 centers in Germany and Canada were analyzed. At 12 months, Kaplan–Meier estimates of atrial tachyarrhythmia recurrence were comparable across etiologies (ICM 32.2%, NI-DCM 32.9%, AF-CM 30.9%; log-rank P=0.91). The pattern of recurrent arrhythmias differed significantly between etiologies (P=0.04), with organized atrial tachycardias most frequent in ICM (25%), intermediate in NI-DCM (19%), and least common in AF-CM (9%). Safety outcomes were similar, with no significant differences in all-cause mortality (2.2% vs. 0.6% vs. 2.0%; P=0.39) or procedure-related adverse events (5.5% vs. 2.3% vs. 3.3%; P=0.19).
Conclusions
In patients with AF and HFrEF undergoing first-time PVI, efficacy and safety are comparable across cardiomyopathy etiologies, while arrhythmia recurrence patterns vary by etiology.12m KM recurrence rates by HFrEF etiology