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Meta-Analysis
. 2024 Jun 1;9(6):545-555.
doi: 10.1001/jamacardio.2024.0675.

Atrial Fibrillation Ablation in Heart Failure With Reduced vs Preserved Ejection Fraction: A Systematic Review and Meta-Analysis

Alireza Oraii  1 , William F McIntyre  1   2 , Ratika Parkash  3 , Krzysztof Kowalik  4 , Ghazal Razeghi  4 , Alexander P Benz  1 , Emilie P Belley-Côté  1   2 , David Conen  1   2 , Stuart J Connolly  1   2 , Anthony S L Tang  5 , Jeff S Healey  1   2 , Jorge A Wong  1   2
Affiliations
Meta-Analysis

Atrial Fibrillation Ablation in Heart Failure With Reduced vs Preserved Ejection Fraction: A Systematic Review and Meta-Analysis

Alireza Oraii et al. JAMA Cardiol. .

Abstract

Importance: Catheter ablation is associated with reduced heart failure (HF) hospitalization and death in select patients with atrial fibrillation (AF) and heart failure with reduced ejection fraction (HFrEF). However, the benefit in patients with HF with preserved ejection fraction (HFpEF) is uncertain.

Objective: To investigate whether catheter ablation for AF is associated with reduced HF-related outcomes according to HF phenotype.

Data source: A systematic search of MEDLINE, Embase, and Cochrane Central was conducted among studies published from inception to September 2023.

Study selection: Parallel-group randomized clinical trials (RCTs) comparing catheter ablation with conventional rate or rhythm control therapies in patients with HF, New York Heart Association functional class II or greater, and a history of paroxysmal or persistent AF were included. Pairs of independent reviewers screened 7531 titles and abstracts, of which 12 RCTs and 4 substudies met selection criteria.

Data extraction and synthesis: Data were abstracted in duplicate according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Pooled effect estimates were calculated using random-effects Mantel-Haenszel models. Interaction P values were used to test for subgroup differences.

Main outcomes and measures: The primary outcome was HF events, defined as HF hospitalization, clinically significant worsening of HF, or unscheduled visits to a clinician for treatment intensification. Secondary outcomes included cardiovascular and all-cause mortality.

Results: A total of 12 RCTs with 2465 participants (mean [SD] age, 65.3 [9.7] years; 658 females [26.7%]) were included; there were 1552 participants with HFrEF and 913 participants with HFpEF. Compared with conventional rate or rhythm control, catheter ablation was associated with reduced risk of HF events in HFrEF (risk ratio [RR], 0.59; 95% CI, 0.48-0.72), while there was no benefit in patients with HFpEF (RR, 0.93; 95% CI, 0.65-1.32) (P for interaction = .03). Catheter ablation was associated with reduced risk of cardiovascular death compared with conventional therapies in HFrEF (RR, 0.49; 95% CI, 0.34-0.70) but a differential association was not detected in HFpEF (RR, 0.91; 95% CI, 0.46-1.79) (P for interaction = .12). Similarly, no difference in the association of catheter ablation with all-cause mortality was found between HFrEF (RR vs conventional therapies, 0.63; 95% CI, 0.47-0.86) and HFpEF (RR vs conventional therapies, 0.95; 95% CI, 0.39-2.30) groups (P for interaction = .39).

Conclusions and relevance: This study found that catheter ablation for AF was associated with reduced risk of HF events in patients with HFrEF but had limited or no benefit in HFpEF. Results from ongoing trials may further elucidate the role of catheter ablation for AF in HFpEF.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr McIntyre reported receiving personal fees from Trimedic Therapeutics outside the submitted work. Dr Benz reported receiving personal fees from Bristol Myers Squibb (BMS) and AstraZeneca outside the submitted work and participating in an educational program supported by Boston Scientific (“Fellowship Herzrhythmus”). Dr Belley-Côté reported receiving grants from Abbott, Bayer, BMS-Pfizer, Roche Diagnostics, and Trimedic Therapeutics outside the submitted work. Dr Conen reported receiving personal fees from Roche Diagnostics, Trimedic Therapeutics, and Servier outside the submitted work. Dr Healey reported receiving grants from Boston Scientific and Medtronic outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Study Flowchart
Figure 2.
Figure 2.. Efficacy of Catheter Ablation in Reduction of Heart Failure (HF) Events
Outcomes are shown in A, patients with HF overall and B, patients with heart failure with reduced ejection fraction (HFrEF) vs those with heart failure with preserved ejection fraction (HFpEF). M-H indicates Mantel-Haenszel; NA, not applicable.
Figure 3.
Figure 3.. Efficacy of Catheter Ablation in Reduction of Cardiovascular Mortality
Outcomes are shown in A, patients with heart failure overall and B, patients with heart failure with reduced ejection fraction (HFrEF) vs those with heart failure with preserved ejection fraction (HFpEF). M-H indicates Mantel-Haenszel; NA, not applicable.
Figure 4.
Figure 4.. Efficacy of Catheter Ablation in Reduction of All-Cause Mortality
Outcomes are shown in A, patients with heart failure overall and B, patients with heart failure with reduced ejection fraction (HFrEF) vs those with heart failure with preserved ejection fraction (HFpEF). M-H indicates Mantel-Haenszel; NA, not applicable.
See this image and copyright information in PMC

Comment in

References

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