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Early Catheter Ablation for AF After HF Admission
Quick Takes
- In a Japanese registry of patients hospitalized with HF, early catheter ablation (within 90 days of discharge) for comorbid AF was associated with reduced all-cause mortality.
- These observational findings will need to be confirmed in randomized controlled trials prior to widespread practice change.
Study Questions:
Among patients hospitalized for heart failure (HF), what is the association between early catheter ablation for atrial fibrillation (AF) and mortality?
Methods:
This study used the JROADHF (Japanese Registry of Acute Decompensated Heart Failure), which is a retrospective registry of hospitalized patients (n = 13,238) with heart failure at 128 sites in Japan in the year 2013. Patients with acute myocardial infarction were excluded from the registry. This study also used Japanese administrative claims data.
Included in this analysis were registry patients with comorbid AF. Excluded were patients dying within 90 days of hospital discharge or patients without outcomes data. Of this subset of patients, administrative claims data were used to identify which underwent early catheter ablation for AF within 90 days of discharge (intervention group, n = 103) and which did not (control group, n = 2,683). A propensity match cohort was examined as well (n = 83 for each group). The primary endpoint of this study was all-cause mortality after hospital discharge. Secondary endpoints included cardiovascular (CV) mortality and HF mortality.
Results:
The median follow-up time for this study was 4.1 years (95% confidence interval [CI], 3.5-4.5 years). The group undergoing early AF ablation was more likely to be younger, be male, have higher estimated glomerular filtration rate, have paroxysmal AF, have HF with reduced ejection fraction (HFrEF), and have smaller left atrial size. The early ablation group was also less likely to have prior HF hospitalizations. For the early ablation group, the median time to ablation was 29.0 days (interquartile range, 13.0-49.0 days).
In the time-to-event analysis, all-cause mortality was lower in the early ablation compared to the control group (hazard ratio [HR], 0.38; 95% CI, 0.24-0.60; p < 0.001). Early ablation compared to control was also associated with lower CV (HR, 0.28; 95% CI, 0.13-0.63; p < 0.001) and HF (HR, 0.31; 95% CI, 0.13-0.75; p = 0.005) mortality. Similar trends were seen with the propensity-matched cohort, with early ablation being associated with lower all-cause mortality (HR, 0.47; 95% CI, 0.25-0.88; p = 0.014).
Conclusions:
Among patients hospitalized with HF and comorbid AF, early catheter ablation for AF was associated with lower all-cause mortality compared to not receiving early ablation.
Perspective:
Patients with HF commonly have concurrent AF. Rhythm control strategies are often pursued in this patient population with the hope that maintenance of sinus rhythm will prevent progression of HF and further cardiac remodeling. Prior studies have demonstrated potential benefits of rhythm control for AF in certain patients with HF, as well as benefit of catheter ablation over antiarrhythmic medications. However, there is still much to be learned about which patients with HF will benefit from catheter ablation and what procedural aspects (timing of procedure, procedural details) are important to consider. This current study begins to address this through retrospective, observational data and demonstrated impressive associations with early catheter ablation and reduced all-cause mortality. However, given the limitations of the study (observational, small, matched cohort size, lack of granular procedural and AF data, possible selection bias), these findings will have to be confirmed with randomized studies prior to widespread practice change. The impact of newer ablation technology and techniques will also need to be assessed given this registry data are about a decade old.
Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Prevention, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure
Keywords: Ablation Techniques, Anticoagulants, Arrhythmias, Cardiac, Catheter Ablation, Comorbidity, Heart Failure, Patient Admission, Patient Discharge, Secondary Prevention, Stroke Volume
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