Atrial Fibrillation Ablation for Heart Failure With Preserved Ejection Fraction: A Randomized Controlled Trial

David Chieng; Hariharan Sugumar; Louise Segan; Caleb Tan; Donna Vizi; Shane Nanayakkara; Ahmed Al-Kaisey; Joshua Hawson; Sandeep Prabhu; Aleksandr Voskoboinik; Sue Finch; Joseph B Morton; Geoffrey Lee; Justin Mariani; Andre La Gerche; Andrew J Taylor; Erin Howden; Peter M Kistler; Jonathan M Kalman; David M Kaye; Liang-Han Ling

doi:10.1016/j.jchf.2023.01.008

Atrial Fibrillation Ablation for Heart Failure With Preserved Ejection Fraction: A Randomized Controlled Trial

JACC Heart Fail. 2023 Jun;11(6):646-658. doi: 10.1016/j.jchf.2023.01.008. Epub 2023 Mar 1.

Authors

David Chieng¹, Hariharan Sugumar¹, Louise Segan¹, Caleb Tan², Donna Vizi³, Shane Nanayakkara³, Ahmed Al-Kaisey⁴, Joshua Hawson⁵, Sandeep Prabhu¹, Aleksandr Voskoboinik¹, Sue Finch⁶, Joseph B Morton⁵, Geoffrey Lee⁵, Justin Mariani⁷, Andre La Gerche⁸, Andrew J Taylor¹, Erin Howden², Peter M Kistler⁹, Jonathan M Kalman¹⁰, David M Kaye¹¹, Liang-Han Ling¹²

Affiliations

¹ Department of Cardiology, Alfred Hospital, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia.
² Department of Cardiology, Alfred Hospital, Melbourne, Australia.
³ Department of Cardiology, Alfred Hospital, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia.
⁴ Department of Cardiology, Alfred Hospital, Melbourne, Australia; University of Melbourne, Melbourne, Australia; Royal Melbourne Hospital, Melbourne, Australia.
⁵ University of Melbourne, Melbourne, Australia; Royal Melbourne Hospital, Melbourne, Australia.
⁶ University of Melbourne, Melbourne, Australia.
⁷ The Baker Heart and Diabetes Research Institute, Melbourne, Australia.
⁸ The Baker Heart and Diabetes Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia.
⁹ Department of Cardiology, Alfred Hospital, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia; Monash University, Melbourne, Australia.
¹⁰ University of Melbourne, Melbourne, Australia; Royal Melbourne Hospital, Melbourne, Australia; Monash University, Melbourne, Australia.
¹¹ Department of Cardiology, Alfred Hospital, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia; Monash University, Melbourne, Australia. Electronic address: d.kaye@alfred.org.au.
¹² Department of Cardiology, Alfred Hospital, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia. Electronic address: hling@heartrhythmclinic.com.au.

PMID: 36868916
DOI: 10.1016/j.jchf.2023.01.008

Abstract

Background: Patients with heart failure with preserved ejection fraction (HFpEF) frequently develop atrial fibrillation (AF). There are no randomized trials examining the effects of AF ablation on HFpEF outcomes.

Objectives: The aim of this study is to compare the effects of AF ablation vs usual medical therapy on markers of HFpEF severity, including exercise hemodynamics, natriuretic peptide levels, and patient symptoms.

Methods: Patients with concomitant AF and HFpEF underwent exercise right heart catheterization and cardiopulmonary exercise testing. HFpEF was confirmed with pulmonary capillary wedge pressure (PCWP) of 15 mm Hg at rest or ≥25 mm Hg on exercise. Patients were randomized to AF ablation vs medical therapy, with investigations repeated at 6 months. The primary outcome was change in peak exercise PCWP on follow-up.

Results: A total of 31 patients (mean age: 66.1 years; 51.6% females, 80.6% persistent AF) were randomized to AF ablation (n = 16) vs medical therapy (n = 15). Baseline characteristics were comparable across both groups. At 6 months, ablation reduced the primary outcome of peak PCWP from baseline (30.4 ± 4.2 to 25.4 ± 4.5 mm Hg; P < 0.01). Improvements were also seen in peak relative VO₂ (20.2 ± 5.9 to 23.1 ± 7.2 mL/kg/min; P < 0.01), N-terminal pro-B-type natriuretic peptide levels (794 ± 698 to 141 ± 60 ng/L; P = 0.04), and MLHF (Minnesota Living with Heart Failure) score (51 ± -21.9 to 16.6 ± 17.5; P < 0.01). No differences were detected in the medical arm. Following ablation, 50% no longer met exercise right heart catheterization-based criteria for HFpEF vs 7% in the medical arm (P = 0.02).

Conclusions: AF ablation improves invasive exercise hemodynamic parameters, exercise capacity, and quality of life in patients with concomitant AF and HFpEF.

Keywords: N-terminal pro–B-type natriuretic peptide; VO(2); ablation; atrial fibrillation; brain natriuretic peptide; heart failure with preserved ejection fraction; peak pulmonary capillary wedge pressure.

Publication types

Randomized Controlled Trial

MeSH terms

Aged
Atrial Fibrillation* / complications
Atrial Fibrillation* / surgery
Female
Heart Failure* / complications
Humans
Male
Pulmonary Wedge Pressure
Quality of Life
Stroke Volume