Catheter treatment of atrial fibrillation in patients with left ventricular systolic dysfunction: analysis of early postoperative results

Atrial fibrillation (AF) is a significant cause of chronic heart failure development. The results of randomized clinical trials focusing on interventional treatment of AF in patients with systolic left ventricular (LV) dysfunction demonstrate varying effectiveness and safety of catheter interventions. 
Objective. The main aim of this study is to evaluate the efficacy and safety of catheter ablation of AF in patients with systolic LV dysfunction compared to patients without systolic LV dysfunction. 
Material and methods. Following “pseudo-randomization” 395 patients who underwent pulmonary vein isolation were divided into 2 groups: the main group (LV ejection fraction < 50%, n = 42) and the comparison group (LV ejection fraction ≥ 50%, n = 81).
Results. There was no statistically significant difference between the main group and the comparison group in the frequency of postoperative AF recurrence during hospitalization (7.1% (3) vs. 14.8% (12), p = 0.218), the frequency of intraoperative complications (2.4% vs. 9.9%, p = 0.130), and their structure (p = 0.442). The main group showed an increase in LV ejection fraction by +6.6 ± 7.9% on the 2nd day post-operation (p < 0.001), primarily due to the control of tachysystole and restoration of sinus rhythm in the presence of viable LV myocardium. 
Conclusion. Interventional treatment of AF in patients with systolic LV dysfunction is comparable in safety and efficacy to outcomes in cases with preserved LV ejection fraction.

1. Hindricks G., Potpara T., Dagres N., Arbelo Е., Bax J.J., Blomstrӧm-Lundqvist С. et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Russian Journal of Cardiology. 2021;26(9):4701. (In Russian). DOI: 10.15829/1560-4071-2021-4701

2. Polyakov D.S., Fomin I.V., Belenkov Yu.N., Mareev V.Yu., Ageev F.T., Artemjeva E.G. et al. Chronic heart failure in the Russian Federation: what has changed over 20 years of follow-up? Results of the EPOCH-CHF study. Kardiologiia. 2021;61(4):4–14. (In Russian). DOI: 10.18087/cardio.2021.4.n1628

3. Zhirov I.V., Safronova N.V., Osmolovskaya Yu.F., Тereschenko S.N. Prognostic value of atrial fibrillation in patients with heart failure and different left ventricular ejection fraction: results of the multicenter RIF-CHF register. Russian Journal of Car diology. 2021;26(1):4200. (In Russian). DOI: 10.15829/1560-4071-2021-4200

4. MacDonald M.R., Connelly D.T., Hawkins N.M., Steedman T., Payne J., Shaw M. et al. Radiofrequency ablation for persistent atrial fibrillation in patients with advanced heart failure and severe left ventricular systolic dysfunction: a randomised controlled trial. Heart. 2011;97(9):740–7. DOI: 10.1136/hrt.2010.207340. Epub 2010 Nov 4. PMID: 21051458.

5. Kuck K.H., Merkely B., Zahn R., Arentz T., Seidl K., Schlüter M. et al. Catheter ablation versus best medical therapy in patients with persistent atrial fibrillation and congestive heart failure: the randomized AMICA Trial. Circ. Arrhythm. Electrophysiol. 2019;12(12):e007731. DOI: 10.1161/CIRCEP.119.007731. Epub 2019 Nov 25. PMID: 31760819.

6. Parkash R., Wells G.A., Rouleau J., Talajic M., Essebag V., Skanes A. et al. Randomized ablation-based rhythm-control versus rate-control trial in patients with heart failure and atrial fibrillation: results from the RAFT-AF trial. Circulation. 2022;145(23):1693–1704. DOI: 10.1161/CIRCULATIONAHA.121.057095. Epub 2022 Mar 22. PMID: 35313733.

7. Jones D.G., Haldar S.K., Hussain W., Sharma R., Francis D.P., Rahman-Haley S.L. et al. A randomized trial to assess catheter ablation versus rate control in the management of persistent atrial fibrillation in heart failure. J. Am. Coll. Cardiol. 2013;61(18):1894–903. DOI: 10.1016/j.jacc.2013.01.069

8. Khan M.N., Jaïs P., Cummings J., Di Biase L., Sanders P., Martin DO.et al. PABA-CHF Investigators. Pulmonary-vein isolation for atrial fibrillation in patients with heart failure. N. Engl. J. Med. 2008;359(17):1778–85. DOI: 10.1056/NEJMoa0708234

9. Hunter R.J., Berriman T.J., Diab I., Kamdar R., Richmond L., Baker V. et al. A randomized controlled trial of catheter ablation versus medical treatment of atrial fibrillation in heart failure (the CAMTAF trial). Circ. Arrhythm. Electrophysiol. 2014;7(1):31–8. DOI: 10.1161/CIRCEP.113.000806

10. Di Biase L., Mohanty P., Mohanty S., Santangeli P., Trivedi C., Lakkireddy D.et al. Ablation versus amiodarone for treatment of persistent atrial fibrillation in patients with congestive heart failure and an implanted device: results from the AATAC Multicenter Randomized Trial. Circulation. 2016;133(17):1637–44. DOI: 10.1161/CIRCULATIONAHA.115.019406

11. Prabhu S., Taylor A.J., Costello B.T., Kaye D.M., McLellan A.J.A., Voskoboinik A. et al. Catheter ablation versus medical rate control in atrial fibrillation and systolic dysfunction: the CAMERA-MRI study. J. Am. Coll. Cardiol. 2017;70(16):1949–1961. DOI: 10.1016/j.jacc.2017.08.041

12. Sugumar H., Prabhu S., Costello B., Chieng D., Azzopardi S., Voskoboinik A. et al. Catheter ablation versus medication in atrial fibrillation and systolic dysfunction: late outcomes of CAMERA-MRI study. JACC Clin. Electrophysiol. 2020;6(13):1721–1731. DOI: 10.1016/j.jacep.2020.08.019

13. Marrouche N.F., Brachmann J., Andresen D., Siebels J., Boersma L., Jordaens L. et al. CASTLE-AF Investigators. Catheter Ablation for Atrial Fibrillation with Heart Failure. N. Engl. J. Med. 2018;378(5):417–427. DOI: 10.1056/NEJMoa1707855

14. Wang M., Cai S., Ding W., Deng Y., Zhao Q. Efficacy and effects on cardiac function of radiofrequency catheter ablation vs. direct current cardioversion of persistent atrial fibrillation with left ventricular systolic dysfunction. PLoS One. 2017;12(3):e0174510. DOI: 10.1371/journal.pone.0174510

15. Pruszkowska P., Lenarczyk R., Gumprecht J., Jedrzejczyk-Patej E., Mazurek M., Kowalski O. et al. Cryoballoon ablation of atrial fibrillation in patients with advanced systolic heart failure and cardiac implantable electronic devices. Kardiol. Pol. 2018;76(7):1081–1088. DOI: 10.5603/KP.a2018.0068

16. Kosiuk J., Nedios S., Darma A., Rolf S., Richter S., Arya A. et al. Impact of single atrial fibrillation catheter ablation on implantable cardioverter defibrillator therapies in patients with ischaemic and non-ischaemic cardiomyopathies. Europace. 2014;16(9):1322–6. DOI: 10.1093/europace/euu018

17. Bortone A., Boveda S., Pasquié JL., Pujadas-Berthault P., Marijon E., Appetiti A., Albenque J.P. Sinus rhythm restoration by catheter ablation in patients with long-lasting atrial fibrillation and congestive heart failure: impact of the left ventricular ejection fraction improvement on the implantable cardioverter defibrillator insertion indication. Europace. 2009;11(8):1018–23. DOI: 10.1093/europace/eup167

18. Chen M.S., Marrouche N.F., Khaykin Y., Gillinov A.M., Wazni O., Martin D.O. et al. Pulmonary vein isolation for the treatment of atrial fibrillation in patients with impaired systolic function. J. Am. Coll. Cardiol. 2004;43(6):1004–9. DOI: 10.1016/j.jacc.2003.09.056. PMID: 15028358.

19. Ullah W., Ling L.H., Prabhu S., Lee G., Kistler P., Finlay M.C. et al. Catheter ablation of atrial fibrillation in patients with heart failure: impact of maintaining sinus rhythm on heart failure status and longterm rates of stroke and death. Europace. 2016;18(5):679–86. DOI: 10.1093/europace/euv440

20. Pott A., Jäck S., Schweizer C., Baumhardt M., Stephan T., Rattka M. et al. Atrial fibrillation ablation in heart failure patients: improved systolic function after cryoballoon pulmonary vein isolation. ESC Heart Fail. 2020;7(5):2258–2267. DOI: 10.1002/ehf2.12735

21. Ma C.M., He Y.J., Li W.W., Tang H.M., Dai S.Y., Yin X.M. et al. Optimal catheter ablation strategy for patients with persistent atrial fibrillation and heart failure: a retrospective study. Cardiol. Res. Pract. 2022;2022:3002391. DOI: 10.1155/2022/3002391. PMID: 35784946; PMCID: PMC9246569.

22. Cha Y.M., Wokhlu A., Asirvatham S.J., Shen W.K., Friedman P.A., Munger T.M. et al. Success of ablation for atrial fibrillation in isolated left ventricular diastolic dysfunction: a comparison to systolic dysfunction and normal ventricular function. Circ. Arrhythm. Electrophysiol. 2011;4(5):724–32. DOI: 10.1161/CIRCEP.110.960690

23. Chen C., Cheng K., Gao X., Zou T., Pang Y., Ling Y.et al. Cryoballoon ablation for atrial fibrillation in patients with heart failure with mildly reduced and preserved ejection fraction. ESC Heart Fail. 2023;10(1):518–531. DOI: 10.1002/ehf2.14212

24. Rosenbaum P.R., Rubin D.B. The central role of the propensity score in observational studies for causal effects. Biometrika. 1983;70(1):41–55. DOI: 10.1093/biomet/70.1.41

25. Richter B, Gwechenberger M, Socas A, Marx M, Gössinger H.D. Frequency of recurrence of atrial fibrillation within 48 hours after ablation and its impact on long-term outcome. Am. J. Cardiol. 2008;101(6):843–7. DOI: 10.1016/j.amjcard.2007.11.021

26. Koyama T., Sekiguchi Y., Tada H., Arimoto T., Yamasaki H., Kuroki K. et al. Comparison of characteristics and significance of immediate versus early versus no recurrence of atrial fibrillation after catheter ablation. Am. J. Cardiol. 2009;103(9):1249–54. DOI: 10.1016/j.amjcard.2009.01.010

27. Lim H.S., Schultz C., Dang J., Alasady M., Lau D.H., Brooks A.G., Wong C.X. et al. Time course of inflammation, myocardial injury, and prothrombotic response after radiofrequency catheter ablation for atrial fibrillation. Circ. Arrhythm. Electrophysiol. 2014;7(1):83– 9. DOI: 10.1161/CIRCEP.113.000876

28. Sørensen S.K., Johannessen A., Worck R., Hansen M.L., Ruwald M.H., Hansen J. Early recurrence of atrial tachyarrhythmia indicates pulmonary vein reconduction independent of blanking period duration in the RACE-AF trial. J. Cardiovasc. Electrophysiol. 2023;34(12):2434–2442. DOI: 10.1111/jce.16098

29. Silva Cunha P., Portugal G., Laranjo S., Alves M., Luísa Papoila A., Valente B. et al. The atrial fibrillation burden during the blanking period is predictive of time to recurrence after catheter ablation. Int. J. Cardiol. Heart Vasc. 2022;43:101138. DOI: 10.1016/j.ijcha.2022.101138

30. Heeger C.H., Abdin A., Mathew S., Reissmann B., Yalin K., Liosis S. et al. Efficacy and safety of cryoballoon ablation in patients with heart failure and reduced left ventricular ejection fraction — a multicenter study. Circ. J. 2019;83(8):1653–1659. DOI: 10.1253/circj.CJ-19-0151

31. Gasimova N.Z., Mikhaylov E.N., Orshanskaya V.S., Kamenev A.V., Tatarsky R.B., Abramov M.L. et al. Reverse remodelling of the heart after atrial fibrillation ablation in patients with heart failure with reduced ejection fraction. Kardiologiia. 2019;59(8S):37–43. (In Russian) DOI: 10.18087/cardio.2671.

32. Sargent S.R., Mladenovic J.R., Liaw J.J.T., Siller J., Russell P.L., Tung M.K.Y., Holland D.J. Catheter ablation for atrial fibrillation-influence of modifiable risk factors and ablation modality on procedural efficacy and safety. Heart Lung Circ. 2024:S1443–9506(24)00125–2. DOI: 10.1016/j.hlc.2024.02.009. Epub ahead of print. PMID: 38570259.

33. Verhaert D.V.M., Brunner-La Rocca H.P., van Veldhuisen D.J., Vernooy K. The bidirectional interaction between atrial fibrillation and heart failure: consequences for the management of both diseases. Europace. 2021;23(2):ii40–ii45. DOI: 10.1093/europace/euaa368. PMID: 33837758; PMCID: PMC8035705.