Efficacy of Catheter Ablation in Atrial Fibrillation Patients With Pulmonary Hypertension

INTRODUCTION: Atrial fibrillation (AF) frequently coexists with pulmonary hypertension (PH) and is associated with clinical deterioration, right ventricular dysfunction, and increased mortality. While catheter ablation has demonstrated superiority over anti-arrhythmic drug (AAD) therapy in select AF populations, outcomes in patients with concurrent PH remain poorly characterized. METHODS: We performed a retrospective cohort study using the TriNetX Research Network. Adults with AF and PH were identified and stratified by treatment with catheter ablation plus AAD or AAD therapy alone. After 1:1 propensity score matching for demographics, comorbidities, and medication use, 9759 patients were included in each cohort. The primary outcomes were major adverse cardiovascular events (MACE) and right heart failure. Secondary outcomes included all-cause mortality, acute myocardial infarction (MI), and stroke. Kaplan-Meier models were used as the primary analysis, with Cox proportional hazards and E-value analysis as sensitivity. Competing risk analyses were performed using Fine-Gray models. RESULTS: Ablation was associated with a 50% reduction in MACE (HR 0.497 [0.467, 0.528], p < 0.001) and 35% reduction in right heart failure (HR 0.647 [0.573, 0.732], p < 0.001). There were also significant reductions in all-cause mortality (HR 0.469 [0.454, 0.488], p < 0.001) and stroke (HR 0.819 [0.728, 0.922], p = 0.001). There was no difference in acute MI (HR 0.982 [0.891, 1.082], p = 0.710). Findings were consistent across Cox sensitivity analyses, E-value analysis, and competing-risk models. CONCLUSION: In AF patients with PH, catheter ablation with AAD therapy was associated with substantially lower risks of adverse cardiovascular outcomes compared with AAD therapy alone. These findings suggest that catheter ablation is associated with lower risks of adverse cardiovascular outcomes in this high-risk population.