Long-term heart failure improvement after catheter ablation of persistent atrial fibrillation in heart failure with preserved, mildly reduced and reduced ejection fraction

Abstract Background Atrial fibrillation (AF) and heart failure (HF) often coexist and are associated with significant morbidity and mortality. While a benefit of AF catheter ablation has been reported in HF with reduced ejection fraction (HFrEF), it remains less well established in HF with preserved (HFpEF) and with mildly reduced (HFmrEF) ejection fraction. Purpose To characterize long-term changes in HF status after catheter ablation of persistent AF (persAF) in HF subgroups based on systematic clinical, echocardiographic and biomarker assessment. Methods We analyzed n=123 consecutive patients referred for first-time catheter ablation of persAF, who were included in the prospective MCAT AF-HF registry from April 2022 to July 2023. All patients received standardized clinical assessment, echocardiography and N-terminal pro-B-type natriuretic peptide (NT-proBNP) measurements at baseline and at 12-month follow-up visits. HF classification was performed according to current European guidelines. Optimal medical therapy was established in all patients at least 4 weeks prior to catheter ablation. The radiofrequency ablation procedure included pulmonary vein isolation ± additional substrate ablation. Results HF incidence among study participants was 69.9% (HFpEF n=46, HFmrEF n=31, HFrEF n=9). Mean age was 70.4 ± 9.4 in HFpEF, 66.5 ± 6.9 in HFmrEF and 65.0 ± 9.6 years in HFrEF (p=0.070). Significant differences in female sex (54.4% vs. 29.0% vs. 11.1%, p=0.014), left ventricular ejection fraction (LVEF 55.3 ± 5.5 vs. 45.2 ± 2.8 vs. 33.1 ± 4.3%, p<0.001) and mean HF-related hospitalization rates (0.4 ± 0.9 vs. 0.3 ± 0.5 vs. 1.3 vs. 0.9, p=0.003) were observed between groups at baseline. At 12-month follow-up, 71.1% HFpEF, 74.2% HFmrEF and 77.8% HFrEF patients were in sinus rhythm (p=0.901). LVEF improved significantly in HFmrEF and HFrEF patients, while a significant decrease in left atrial area and NT-proBNP levels were observed in all groups (Figure 1). Improvement in NYHA class was found in 69.2% HFpEF, 63.0% HFmrEF and 75.0% HFrEF patients (p=0.774). The highest relative improvement in LVEF (34.1 ± 3.3 vs. 46.6 ± 6.2%, p=0.001), NT-proBNP (1817 ± 1342 vs. 367 ± 390 pg/ml, p=0.018) and mean 12-month HF-related hospitalization rate (1.2 ± 0.9 vs. 0.0 ± 0.0, p=0.005) was observed in the HFrEF group. Conclusions Catheter ablation of persAF is associated with significant clinical, echocardiographic and biomarker improvements in all HF categories. The highest improvement of HF status was found in patients with HFrEF.Figure 1