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. 2015 Jun 1;1(3):200-209.
doi: 10.1016/j.jacep.2015.02.018.

Catheter Ablation for Atrial Fibrillation in Heart Failure Patients: A Meta-Analysis of Randomized Controlled Trials

Shadi Al Halabi  1 , Mohammed Qintar  1 , Ayman Hussein  1 , M Chadi Alraies  2 , David G Jones  3 , Tom Wong  3 , Michael R MacDonald  4 , Mark C Petrie  5 , Daniel Cantillon  1 , Khaldoun G Tarakji  1 , Mohamed Kanj  1 , Mandeep Bhargava  1 , Niraj Varma  1 , Bryan Baranowski  1 , Bruce L Wilkoff  1 , Oussama Wazni  1 , Thomas Callahan  1 , Walid Saliba  1 , Mina K Chung  1
Affiliations

Catheter Ablation for Atrial Fibrillation in Heart Failure Patients: A Meta-Analysis of Randomized Controlled Trials

Shadi Al Halabi et al. JACC Clin Electrophysiol. .

Abstract

Background: Rhythm control with antiarrhythmic drugs (AADs) is not superior to rate control in patients with heart failure (HF) and atrial fibrillation (AF), but AF ablation may be more successful at achieving rhythm control than AADs. However, risks for both ablation and AADs are likely higher and success rates lower in patients with HF.

Objective: To compare rate control versus AF catheter ablation strategies in patients with AF and HF.

Methods: We conducted a meta-analysis of trials which randomized HF patients (LVEF<50%) with AF to a rate control or AF catheter ablation strategy and reported change in LVEF, quality of life, 6-minute walk test, or peak oxygen consumption. Study quality and heterogenity were assessed using Jadad scores and Cochran's Q statistics, respectively. Mantel Haenszel relative risks and mean differences were calculated using random effect models.

Results: Four trials (N=224) met inclusion criteria; 82.5% (n=185) had persistent AF. AF ablation was associated with an increase in LVEF (mean difference 8.5%; 95%CI 6.4,10.7%; P<0.001) compared to rate control. AF ablation was superior in improving quality of life by Minnesota Living with Heart Failure (MLWHF) questionnaire scores (mean difference -11.9; 95%CI -17.1, -6.6; P<0.001). Peak oxygen consumption and 6-minute walk distance increased in AF ablation compared to rate control patients (mean difference 3.2; 95%CI 1.1,5.2; P=0.003; mean difference 34.8; 95%CI 2.9, 66.7; P = 0.03, respectively). In the persistent AF subgroup LVEF and MLWHF were significantly improved with AF ablation. Major adverse event rates (RR 1.3; 95% CI, 0.4, 3.9; p=0.64) were not significantly different. No significant heterogeneity was evident.

Conclusions: In patients with HF and AF, AF catheter ablation is superior to rate control in improving LVEF, quality of life and functional capacity. Prior to accepting a rate control strategy in HF patients with persistent or drug refractory AF, consideration should be given to AF ablation.

Keywords: Atrial fibrillation; catheter ablation; heart failure; pulmonary vein isolation.

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Figures

Figure 1
Figure 1
PRISMA diagram showing search strategy results and exclusion steps.
Figure 2
Figure 2. Changes in Functional Outcomes
A. Change in LVEF. B. Change in MLWHF. C. Change in 6-Minute Walk Test Distance. D. Change in Peak VO2. Mean difference (MD) and 95% confidence intervals (CI) in studies comparing AF catheter ablation to rate control in HF patients.
Figure 3
Figure 3. Adverse Outcomes
A. Major Adverse Events. B. All Adverse Events. C. Heart Failure Re-admissions. Odds ratios (OR) and 95% confidence intervals (CI) in studies comparing AF catheter ablation to rate control in HF patients.
See this image and copyright information in PMC

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