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Catheter Ablation Versus Medication in Atrial Fibrillation and Systolic Dysfunction: Late Outcomes of CAMERA-MRI
Hariharan Sugumar1, Sandeep Prabhu2, Ben Costello3
1Department of Cardiology, The Baker Heart Research Institute, Melbourne, Australia; Department of Cardiology, The Alfred Hospital, Melbourne, Australia; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Department of Cardiology, University of Melbourne, Melbourne, Australia.
Insights
Catheter ablation (CA) significantly improves long-term left ventricular ejection fraction (LVEF) in patients with atrial fibrillation and heart failure compared to medical rate control (MRC). Absence of ventricular fibrosis on MRI indicates better LVEF recovery.
Area of Science:
- Cardiology
- Electrophysiology
- Heart Failure Management
Background:
- Persistent atrial fibrillation (AF) with systolic heart failure poses significant management challenges.
- Previous studies indicated short-term benefits of catheter ablation (CA) over medical rate control (MRC) for improving left ventricular ejection fraction (LVEF).
- Long-term outcomes of CA versus MRC in this patient population remained largely unreported.
Purpose of the Study:
- To evaluate the long-term efficacy of restoring sinus rhythm via catheter ablation (CA) compared to medical rate control (MRC).
- To assess the impact of CA on left ventricular ejection fraction (LVEF) over a 4-year follow-up period.
- To investigate predictors of LVEF recovery following CA in patients with persistent AF and heart failure.
Main Methods:
- The CAMERA-MRI study randomized 66 patients with persistent AF and heart failure to CA or MRC.
- Patients were followed for 4 years using echocardiography and cardiac magnetic resonance (CMR) imaging.
- Arrhythmia burden was monitored, and crossover from MRC to CA was permitted after 6 months.
Main Results:
- Catheter ablation (CA) resulted in a significantly greater absolute increase in LVEF (16.4 ± 13.3%) compared to medical rate control (MRC) (8.6 ± 7.6%) over 4 years (p=0.001).
- Atrial fibrillation recurrence occurred in 57% of patients in the CA group after a mean of 1.4 procedures.
- Absence of ventricular late gadolinium enhancement (fibrosis) on CMR was associated with significantly greater LVEF improvement and normalization (p=0.04 and p=0.008, respectively).
Conclusions:
- Catheter ablation (CA) demonstrates superior long-term efficacy over medical rate control (MRC) in improving LVEF in patients with atrial fibrillation and systolic heart failure.
- The absence of ventricular fibrosis, as assessed by cardiac magnetic resonance, is a key predictor of substantial systolic function recovery after CA.
- Restoring sinus rhythm through CA offers a durable benefit for heart failure management in selected AF patients.
Objectives:
This study sought to determine the long-term outcomes of restoring sinus rhythm with catheter ablation (CA).
Background:
The CAMERA-MRI (Catheter Ablation Versus Medical Rate Control in Atrial Fibrillation and Heart Failure-An MRI-Guided Multicenter Randomized Controlled Trial) study demonstrated that restoration of sinus rhythm with CA significantly improved left ventricular ejection fraction (LVEF) compared with medical rate control (MRC) at 6 months in persistent atrial fibrillation and otherwise unexplained systolic heart failure. However, the long-term outcomes have not been reported.
Methods:
Patients enrolled in the CAMERA-MRI study were followed for 4 years with echocardiogram and cardiac magnetic resonance. CA involved pulmonary vein isolation and posterior left atrial wall isolation in 94%. Patients crossed over to CA after 6-month study duration. Arrhythmia burden was determined with implanted cardiac monitors or cardiac devices.
Results:
Sixty-six patients (age 62 ± 10 years, atrial fibrillation duration of 22 ± 16 months, and LVEF 33 ± 9%) were randomized 1:1 to CA versus MRC. Eighteen of 33 patients crossed over from MRC group to CA group. At 4.0 ± 0.9 years, atrial fibrillation recurred in 27 patients (57%) in the CA group with a mean burden of 10.6 ± 21.2% after 1.4 ± 0.6 procedures. There was an absolute increase in LVEF with CA of 16.4 ± 13.3% compared with 8.6 ± 7.6% in MRC (p = 0.001). In the CA group, the absence of ventricular late gadolinium enhancement was associated with a greater improvement in absolute LVEF (19 ± 13% vs. 10 ± 11% in the late gadolinium enhancement-positive group; p = 0.04) and LVEF normalization in 19 patients (58%) versus 4 patients (18%) in the late gadolinium enhancement-positive group (p = 0.008) at 4.0 ± 0.9 years follow-up.
Conclusions:
CA is superior to MRC in improving LVEF in the long term in patients with atrial fibrillation and systolic heart failure. The greatest recovery in systolic function was demonstrated in the absence of ventricular fibrosis on cardiac magnetic resonance.
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