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Randomized Controlled Trial
. 2025 May;13(5):785-794.
doi: 10.1016/j.jchf.2025.01.029. Epub 2025 Apr 16.

Effects of Atrial Fibrillation Ablation for Heart Failure With Preserved Ejection Fraction: Insights From CABANA

Pieter Martens  1 , Silvio Nunes Augusto Jr  2 , Jonas Erzeel  3 , Laurent Pison  4 , Wilfried Mullens  3 , W H Wilson Tang  5
Affiliations
Free article
Randomized Controlled Trial

Effects of Atrial Fibrillation Ablation for Heart Failure With Preserved Ejection Fraction: Insights From CABANA

Pieter Martens et al. JACC Heart Fail. 2025 May.
Free article

Abstract

Background: Atrial fibrillation (AF) ablation is Class I recommendation in selected heart failure (HF) patients with reduced ejection fraction; less is known in heart failure with preserved ejection fraction (HFpEF).

Objectives: The aim of this study was to investigate the effects of AF ablation in patients with HFpEF.

Methods: The CABANA (Catheter Ablation vs Antiarrhythmic Drug Therapy for Atrial Fibrillation) trial randomized patients with cardiovascular risk factors for stroke to AF ablation vs drug therapy. The presence of a high likelihood of HFpEF at enrollment was determined by a modified H2FPEF score of ≥6. Treatment effects of baseline HFpEF likelihood on the AF ablation for death and cardiovascular admission, AF recurrence, and functional status were assessed.

Results: A total of 1,763 patients were included in the analysis. A high modified H2FPEF score (55% of the entire cohort) resulted in a significant treatment effect modulation (P for interaction = 0.027), with a lower risk for cardiovascular hospitalization or death in patients with a high likelihood of HFpEF (HR: 0.82 [95% CI: 0.69-0.98]; P = 0.025), but not in patients without (HR: 1.00 [95% CI: 0.82-1.22]; P = 0.987). Although patients with a high likelihood of HFpEF were at a higher risk for AF recurrence, the greatest treatment effect of AF ablation on AF recurrence was observed in patients with a high likelihood of HFpEF (P for interaction = 0.035). In a sensitivity analysis in a subset of patients with echocardiographic evidence of HFpEF (n = 225), a similar treatment interaction was found.

Conclusions: In patients undergoing AF ablation, the presence of underlying HFpEF (either by HFpEF probability or defined by echocardiography) was associated with a larger benefit with AF ablation on clinical outcome, AF recurrence, and functional status. (Catheter Ablation vs Antiarrhythmic Drug Therapy for Atrial Fibrillation [CABANA]; NCT00911508).

Keywords: atrial fibrillation; clinical trials; heart failure with preserved ejection fraction.

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Conflict of interest statement

Funding Support and Author Disclosures Dr Martens is supported by a grant from BAEF (Belgian American Educational Foundation) and by the Frans Van de Werf Fund. The BioLINCC (Biologic Specimen and Data Repository Information Coordinating Center) is funded by the National Institutes of Health. Dr Tang is a consultant for Sequana Medical, Cardiol Therapeutics Inc, Genomics plc, Zehna Therapeutics, Boston Scientific, WhiteSwell, Intellia Therapeutics, CardiaTec Biosciences, Bristol Myers Squibb, Alleviant Medical, Alexion Pharmaceuticals, Salubris Biotherapeutics, and BioCardia Inc; and has received honorarium from Springer, Belvoir Media Group, and the American Board of Internal Medicine. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

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