A substantial fraction of patients undergoing catheter ablation (CA) for atrial fibrillation (AFib) had heart failure (HF), with this subset experiencing higher complication rates, and those with heart failure with reduced ejection fraction (HFrEF) undergoing more adjunctive ablation beyond pulmonary vein isolation than those with heart failure with preserved ejection fraction (HFpEF) or without HF, according to a retrospective analysis of data from the ACC NCDR Atrial Fibrillation Ablation registry published July 28 in Heart Rhythm.

Of 75,527 patients in the registry who underwent first-time CA, investigators Omair Yousuf, MD, et al., found 68% (n=51,285) did not have HF, 18% (n=13,625) had HFrEF and 14% (n=10,617) had HFpEF. The patients were about 66 years old on average and mostly men (60-80%).

Patients with HF tended to have more comorbidities, including hypertension, diabetes, prior thromboembolic events, sleep apnea and prior stroke or transient ischemic attacks (TIA).

Results also showed that patients with HFrEF had higher rates of adjunctive ablation than those with HFpEF or no HF – in both linear ablation (32% of the HFrEF arm vs. 29% of the HFpEF arm vs. 24% of the no-HF arm) and cavotricuspid isthmus ablation (33% vs. 30% vs. 30%, respectively; p<0.0001 for both).

In what the researchers describe as the largest prospective registry of patients undergoing AFib CA, they note that while their data indicate that CA is a "safe procedure with relatively low complication rates," those rates were higher in patients with than without HF, mostly driven by higher rates of acute HF exacerbation: 4% in the HFrEF arm (adjusted odds ratio [aOR] 1.80; p<0.0001), 3.8% in the HFpEF arm (aOR 1.42; p<0.0001) and 2% in the no-HF arm. Complications recorded included death, cardiac arrest, cardiac surgery, vascular injury requiring intervention or bleeding requiring transfusion, pericardial effusion requiring intervention, and stroke or TIA.

Looking at trends over time, researchers found that the number of ablations increased from 2018 to 2022, by 138% in the HFrEF arm, by 191% in the HFpEF arm and 113% in the no-HF arm. Of note, the rate of complications dropped significantly from 2016 to 2022 in all three groups: from 5% to 3% in the HFrEF arm, 6% to 3% in the HFpEF arm and from 3% to 2% in the no-HF arm.

"Our data shows even greater improvement than the 30% reduction seen over the years in randomized clinical trials," Yousuf and colleagues write. "Improvement in technology with widespread adoption of contact-force sensing catheters, improved imaging, improved mapping and advancements in periprocedural management likely played a role in the significant improvement in safety."