Left Atrial Appendage Closure With Catheter Ablation vs. Ablation Alone on Outcomes of Atrial Fibrillation in Heart Failure With Reduced Ejection Fraction: A Propensity Score-Matched Analysis

Abstract

Background Combining left atrial appendage closure with catheter ablation (LAACCA) has been proposed as a potential approach to improving outcomes by simultaneously addressing arrhythmia and reducing stroke risk. This study compares the in-hospital outcomes of LAACCA vs. catheter ablation (CA) alone for atrial fibrillation (AFib) in patients with heart failure with reduced ejection fraction (HFrEF). Methods We analyzed adult hospitalizations with HFrEF and AFib who underwent LAACCA or CA alone from the 2016-2020 nationwide inpatient sample using validated ICD-10 codes. Propensity score matching, accounting for patient-, hospital-, and procedure-level covariates, illness severity, and baseline risk of mortality, was used to alleviate bias in nonrandomized treatment assignments. The primary endpoints included all-cause in-hospital mortality, hospital stay, and hospitalization costs. Secondary endpoints included postprocedural complication rates. Prolonged hospitalization was defined as hospital stay in the top decile of hospital stay in each cohort. All statistical analyses in the study were based on weighted hospital data. Results About 233,865 HFrEF patients were hospitalized for AFib. Approximately 27,945 (11.9%) underwent LAACCA, while 205,920 (88.1%) underwent CA only. The cohort comprised mostly males (151,077; 64.6%) (mean age: 67.4; SD: 4.3). The propensity score-matched cohort comprised 18,195 LAACCAs and 18,195 CAs; all covariate imbalances were alleviated. LAACCA was associated with a higher rate of prolonged hospital stay (7.6 vs 5.6 days; P<0.001), a higher mortality rate (209 (1.1%) vs. 160 (0.9%); P=0.011), and higher mean hospital costs ($289,960 vs. $183,932; P<0.001) compared with CA alone. LAACCA was associated with a higher incidence of acute myocardial ischemia (528 (2.9%) vs. 455 (2.5%); P=0.013), complete atrioventricular block (1,200 (6.6%) vs. 892 (4.9%); P=0.004), need for implantable device therapy (1,510 (8.3%) vs. 1,348 (7.4%); P=0.017), pneumothorax (328 (1.8%) vs. 91 (0.5%); P<0.0001), hemothorax (200 (1.1%) vs. 127 (0.7%); P<0.0001), pneumonia (983 (5.4%) vs. 546 (3.0%); P<0.0001), vascular access complications (346 (1.9%) vs. 255 (1.4%); P=0.046), and septicemia (309 (1.7%) vs. 182 (1.0%); P<0.001). CA was associated with a greater incidence of cardiac tamponade (237 (1.3%) vs. 382 (2.1%); P=0.010) and femoral artery pseudoaneurysm (364 (0.2%) vs. 91 (0.5%); P<0.001). Conclusion LAACCA was correlated with higher mortality odds compared to CA alone for atrial fibrillation in HFrEF.

Keywords: atrial fibrillation; catheter ablation; electrocardiogram (ekg) atrial fibrillation (a-fib) with rapid ventricular response (rvr); heart failure; left atrial appendage closure.

Figure 1. Study cohort selection

NIS = nationwide inpatient sample database; ICD-10 CM = international classification of diseases, tenth revision, clinical modification; LAACCA = combined left atrial appendage closure and catheter ablation; CA = catheter ablation only; ICD-10 PCS = international classification of diseases, tenth revision, procedure coding system