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Randomized Controlled Trial
. 2023 Jan;25(1):77-86.
doi: 10.1002/ejhf.2714. Epub 2022 Nov 1.

Long-term outcomes following catheter ablation versus medical therapy in patients with persistent atrial fibrillation and heart failure with reduced ejection fraction

Rosita Zakeri  1   2 , Nikhil Ahluwalia  3 , Alexander Tindale  2   3 , Fatima Omar  2 , Matthew Packer  2 , Habib Khan  2 , Victoria Baker  4 , Shohreh Honarbakhsh  4 , Mark J Earley  4 , Simon Sporton  4 , Richard J Schilling  4 , David Jones  2 , Vias Markides  2 , Ross J Hunter  4 , Tom Wong  1   2 ; ARC-HF and CAMTAF Investigators
Affiliations
Randomized Controlled Trial

Long-term outcomes following catheter ablation versus medical therapy in patients with persistent atrial fibrillation and heart failure with reduced ejection fraction

Rosita Zakeri et al. Eur J Heart Fail. 2023 Jan.

Abstract

Aims: The ARC-HF and CAMTAF trials randomized patients with persistent atrial fibrillation (AF) and heart failure (HF) to early routine catheter ablation (ER-CA) versus pharmacological rate control (RC). After trial completion, delayed selective catheter ablation (DS-CA) was performed where clinically indicated in the RC group. We hypothesized that ER-CA would result in a lower risk of cardiovascular hospitalization and death versus DS-CA in this population.

Methods and results: Overall, 102 patients were randomized (age 60 ± 11 years, left ventricular ejection fraction [LVEF] 31 ± 11%): 52 to ER-CA and 50 to RC. After 12 months, patients undergoing ER-CA had improved self-reported symptom scores, lower New York Heart Association class (i.e. better functional capacity), and higher LVEF compared to patients receiving RC alone. During a median follow-up of 7.8 (interquartile range 3.9-9.9) years, 27 (54%) patients in the RC group underwent DS-CA and 34 (33.3%) patients died, including 17 (32.7%) randomized to ER-CA and 17 (34.0%) randomized to RC. Compared with DS-CA, a strategy of ER-CA exhibited similar risk of all-cause mortality (adjusted hazard ratio [aHR] 0.89, 95% confidence interval [CI] 0.44-1.77, p = 0.731) and combined all-cause mortality or cardiovascular hospitalization (aHR 0.80, 95% CI 0.43-1.47, p = 0.467). However, analyses according to treatment received suggested an association between CA and improved outcomes versus RC (all-cause mortality: aHR 0.43, 95% CI 0.20-0.91, p = 0.028; all-cause mortality/cardiovascular hospitalization: aHR 0.48, 95% CI 0.24-0.94, p = 0.031).

Conclusions: In patients with persistent AF and HF, ER-CA produces similar long-term outcomes to a DS-CA strategy. The association between CA as a treatment received and improved outcomes means there is still a lack of clarity regarding the role of early CA in selected patients. Randomized trials are needed to clarify this question.

Keywords: Atrial fibrillation; Catheter ablation; Heart failure.

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Figures

Figure 1
Figure 1
Study flow chart. DS‐CA, delayed selective catheter ablation; ER‐CA, early routine catheter ablation; RC, rate control.
Figure 2
Figure 2
Kaplan–Meier survival curve, intention‐to‐treat analysis. (A) Death. (B) Death or cardiovascular (CV) hospitalization. CA, catheter ablation.
Figure 3
Figure 3
Kaplan–Meier survival curves showing freedom from arrhythmia recurrence following last ablation, including patients undergoing ablation with rhythm status available at long‐term follow up (n = 78). Long‐term rhythm status not known for one patient undergoing delayed selective catheter ablation (CA).
See this image and copyright information in PMC

References

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