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Optimal Ablation Strategies for Persistent Atrial Fibrillation With Heart Failure: Three-Year Follow-Up of a
Kaige Li1, Xinhua Wang2, Mu Qin1
1Department of Cardiology, Shanghai Jiao Tong University School of Medicine, Shanghai Chest Hospital, China (K.L., M.Q., W.J., Y.Z., S.W., K.X., X.L., X.H.).
Insights
Extensive electrogram-anatomic ablation significantly improved outcomes for heart failure patients with atrial fibrillation. This strategy reduced cardiovascular events and maintained sinus rhythm better than other ablation methods.
Area of Science:
- Cardiology
- Electrophysiology
- Heart Failure Management
Background:
- Catheter ablation improves prognosis in heart failure (HF) and atrial fibrillation (AF) patients.
- Optimal ablation strategy for persistent AF and HF remains undefined.
Purpose of the Study:
- To compare the effectiveness of different catheter ablation strategies in patients with persistent AF and HF.
- To evaluate the impact of ablation strategy on cardiovascular events and rhythm control.
Main Methods:
- A multicenter randomized controlled trial involving 300 patients with persistent AF and HF.
- Patients were randomized to anatomic-guided, electrogram-guided, or extensive electrogram-anatomic-guided ablation.
- Coprimary end points included cardiovascular death/HF hospitalization and sinus rhythm maintenance at 36 months.
Main Results:
- The extensive electrogram-anatomic-guided ablation group showed the lowest composite end point incidence (17.0%) and highest sinus rhythm maintenance rate (62.0%) at 36 months.
- Significant improvements were noted in AF burden, NYHA class, 6-minute walk test, and NT-proBNP across groups.
- Trends were consistent in both HF with reduced and preserved ejection fraction subgroups, with low complication rates.
Conclusions:
- Electrogram-anatomic ablation offers superior long-term rhythm control and reduces cardiovascular events in persistent AF and HF patients.
- This strategy improves symptoms regardless of ejection fraction status.
- The findings support extensive electrogram-anatomic-guided ablation as an optimal strategy for this patient population.
Background:
Catheter ablation has been shown to improve prognosis in patients with heart failure (HF) and atrial fibrillation (AF); however, the optimal ablation strategy remains undefined.
Methods:
In this multicenter, randomized controlled trial, 300 patients with persistent AF and HF, including both HF with reduced ejection fraction (ejection fraction ≤40%) and HF with preserved ejection fraction (ejection fraction >40%, including mid-range ejection fraction [ejection fraction 41% to 50%]), were enrolled and randomized equally to the anatomic-guided ablation, electrogram-guided ablation, and extensive electrogram-anatomic-guided ablation groups, with 100 patients in each group. The coprimary end points were: (1) the composite of cardiovascular death or HF-related hospitalization/urgent visit within 36 months; and (2) maintenance of sinus rhythm at 36 months. Secondary end points included AF burden <1%, New York Heart Association class improvement (≥1 grade), 6-minute walk test change, NT-proBNP (N-terminal pro-B-type natriuretic peptide) reduction, and procedure-related complications. Subgroup analyses were performed for HF with reduced ejection fraction and HF with preserved ejection fraction.
Results:
At 36 months, the extensive electro-anatomic-guided ablation group demonstrated the lowest incidence of the composite end point (17.0%) compared with the electrogram-guided ablation (29.0%) and anatomic-guided ablation (36.0%; overall P=0.010) groups, and the highest rate of sinus rhythm maintenance (62.0%) compared with the electrogram-guided ablation (53.0%) and anatomic-guided ablation (44.0%; P=0.039) groups. Consistent improvements were observed for AF burden <1%, New York Heart Association class, 6-minute walk test, and NT-proBNP. Major complications were low and similar across all groups. These trends were consistent in both the HF with reduced ejection fraction and HF with preserved ejection fraction subgroups.
Conclusions:
Electrogram-anatomic ablation provides superior long-term rhythm control, reduces cardiovascular events, and improves symptoms in patients with persistent AF and HF, regardless of ejection fraction.
Registration:
URL: https://www.clinicaltrials.gov; Unique identifier: NCT07153718.
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