Comparing outcomes after pulmonary vein isolation in patients with systolic and diastolic heart failure

Abstract

Background: The benefit of pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF) and heart failure with reduced ejection fraction (HFrEF) is well established; its efficacy in patients with heart failure preserved ejection fraction (HFpEF) is less clear.

Objective: The objective of the study was to compare AF and heart failure (HF) rehospitalizations after PVI in patients with HFpEF vs HFrEF.

Methods: The IBM MarketScan Database was used to identify patients undergoing PVI for AF. Patients were categorized by HF status: absence of HF, presence of HFrEF, or presence of HFpEF. Primary outcomes were HF and arrhythmia hospitalizations after PVI.

Results: A total of 32,524 patients were analyzed: 27,900 with no HF (86%), 2948 with HFrEF (9%), and 1676 with HFpEF (5%). Compared with those with no HF, both patients with HFrEF and HFpEF were more likely to be hospitalized for HF (hazard ratio [HR] 7.27; P < .01 for HFrEF and HR 9.46; P < .01 for HFpEF) and for AF (HR 1.17; P < .01 for HFrEF and HR 1.74; P < .01 for HFpEF) after PVI. In matched analysis, 23% of patients with HFrEF and 24% patients with HFpEF demonstrated a reduction in HF hospitalizations (P = .31) and approximately one-third demonstrated decreased arrhythmia rehospitalizations (P = .57) in the 6 months after PVI. Compared with those with HFrEF in longer-term follow-up (>1 year), patients with HFpEF were more likely to have HF (HR 1.30; P < .01) and arrhythmia (HR 1.19; P < .01) rehospitalizations.

Conclusion: Reductions in HF and arrhythmia hospitalizations are observed early after PVI across all patients with HF, but patients with HFpEF demonstrate higher HF rehospitalization and arrhythmia recurrence in longer-term follow-up than do patients with HFrEF.

Keywords: Atrial fibrillation; Diastolic dysfunction; Heart failure with preserved ejection fraction; Heart failure with reduced ejection fraction; Pulmonary vein isolation.

Figure 1

Study cohort. A total of 55,176 patients were identified as having undergone pulmonary vein isolation (PVI) for atrial fibrillation from 2013 to 2020. Patients with fewer than 6 months of continuous enrollment before and after PVI (unless patients died) were excluded. Patients having undergone the Maze procedure, atrioventricular (AV) node ablation, or heart transplantation as well as patients receiving a permanent pacemaker (PPM) or implantable cardioverter-defibrillator (ICD) on the day of PVI were also excluded. Patients were stratified into patients with heart failure with reduced ejection fraction (HFrEF), heart failure with preserved ejection fraction (HFpEF), and no history of heart failure (HF).

Figure 2

Percentages of patients with a decrease, no change, or increase in heart failure (HF) and arrhythmia hospitalizations. Percentage of patients (with overall number in parentheses) with a decrease, no change, or increase in the number of HF (A) and atrial fibrillation hospitalizations (B) when comparing the 6-month period after pulmonary vein isolation (PVI) vs the 6-month period before PVI. HFpEF = heart failure with preserved ejection fraction; HFrEF = heart failure with reduced ejection fraction; RR = relative risk.

Figure 3

Heart failure (HF) and arrhythmia hospitalization free survival in the unmatched cohort. In unmatched analysis, patients with no history of HF are less likely to have any HF hospitalization (HFH) and any arrhythmia hospitalization after pulmonary vein isolation than patients with HF with reduced ejection fraction (HFrEF). Patients with HFrEF are less likely to have HFH or arrhythmia hospitalization than patients with HF with preserved ejection fraction (HFpEF) (P < .01). Univariable hazard ratios (HRs) are reported. CI = confidence interval.

Figure 4

Percentages of patients with a decrease, no change, or increase in heart failure (HF) and arrhythmia hospitalizations in the matched cohort analysis. Percentage of patients (with overall number in parentheses) with a decrease, no change, or increase in the number of HF (A) and arrhythmia hospitalizations (B) when comparing the 6-month period after pulmonary vein isolation (PVI) vs the 6-month period before PVI. There are no significant differences between the 2 groups. HFpEF = heart failure with preserved ejection fraction; HFrEF = heart failure with reduced ejection fraction; RR = relative risk.

Figure 5

Heart failure (HF) and arrhythmia hospitalization free survival in the matched cohort. In the matched cohort analysis, patients with HF with reduced ejection fraction (HFrEF) are significantly less likely to have any HF (A) and any atrial flutter or atrial fibrillation hospitalizations after pulmonary vein isolation (B) than patients with HF with preserved ejection fraction (HFpEF). Univariable hazard ratios (HRs) are reported. CI = confidence interval; HFH = heart failure hospitalization.