A new prediction model for left ventricular systolic function recovery after catheter ablation of atrial fibrillation in patients with heart failure: The ANTWOORD Study
Graphical abstract
Upper half of the figure: Independent Predictors of Left Ventricle (LV) systolic function recovery after AF ablation in heart failure (HF) patients are reported with their respective odds ratio.
Lower half of the figure: upper left panel, the weighted 4 predictors used to generate the score are listed. In the lower portion of the image the population divided according to the score is depicted. In the middle panel the likelihood LV systolic function recovery according to the score is shown. In the right upper panel the C-statistics describing the accuracy of the model is reported.
Introduction
Atrial fibrillation (AF) and heart failure (HF) frequently coexist and their relationship is complex. AF is both a precipitant factor of HF and a cause of cardiomyopathy.
Five small to medium-size randomized controlled trials (RCTs) in patients with HF and reduced ejection fraction (HFrEF) provided evidence that AF ablation is more effective than pharmacological rate/rhythm control therapy in improving left ventricular ejection fraction (LVEF) with subsequent improvement in quality of life, heart failure hospitalization and mortality [[1], [2], [3]]. However, the recent randomized AMICA trial showed equal EF improvement between the medically treated patients and patients referred to ablation [4]. Current guidelines recommend catheter ablation “to reverse LV dysfunction in AF patients when tachycardia-induced cardiomyopathy is highly probable” [5]. However, only a variable percentage (9 to 68%) of patients with AF and HF experience LVEF improvement after AF ablation and no guidance exists to identify those patients who will most likely improve LVEF [2,3]. Further evidence to help stratify and identify responders to AF ablation in HF is needed in order to improve patient selection and clinical outcomes.
Our aim was 1) to provide better insights on the time to LV function improvement following AF ablation and its maintenance during long term follow-up; 2) to investigate the predictors of LV function improvement after AF ablation; and 3) to develop a new prediction model for the individualized probability of LV function improvement.
Section snippets
Study design and study population
We conducted an observational, retrospective, single-centre study on consecutive patients undergoing first or repeated AF ablation procedure between 2013 and 2019 at the University Hospital of Antwerp. All patients satisfying the diagnostic criteria for HFrEF or mildly reduced EF (HFmrEF) were included. To establish a diagnosis of HFrEF/HFmrEF, all the following criteria had to be fulfilled: 1) presence of signs/symptoms associated with HF (New York Heart Association [NYHA] class ≥II) at rest
Baseline clinical characteristics
A total of 111 patients (60.7 ± 9.7 years, 68 [61%] male) formed the final study population: sixty (54%) Responders and 51 (46%) Non Responders. The baseline clinical characteristics of the study population are shown in Table 1. Detailed etiological classification is depicted in Fig. S1. Patients in the Responder group had significantly lower CHA2DS2-VASc score, shorter QRS duration and shorter “time from first diagnosis of HF to AF ablation”. Among the Responders, persistent AF and AF
Main findings
The main findings of the current study are: 1) Responders achieved improved AF pattern (less persistent AF), and positive ventricular remodelling despite similar AF recurrence rate as compared to Non-Responders. 2) Responders had shorter QRS duration, less dilated left atria, more frequently an unknown etiology and persistent AF. 3) The newly developed score based on four variables (absence of known underlying etiology, persistent AF, QRS < 120 ms, LAVI<50 mL/m2), accurately predicted LVEF
Conclusions
Patients recovering LV systolic dysfunction after AF ablation have less wide QRS complex, less dilated left atria, less frequently a known etiology and more frequently persistent AF. Patients with AF and HF who recovered LV systolic function after AF ablation, in spite of similar recurrence rate, had lower incidence of persistent AF. Mean time to LV function recovery after AF ablation was close to 5 months. A new score system using four clinical and echocardiographic parameters (QRS duration,
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Conflict of interest
C.T. receives consulting fees/honoraria from Abbott, Medtronic, Boston Scientific, and Biosense Webster, and serves as a member of EU Medtronic Advisory Board and Boston Scientific Advisory Board. The other authors declare no relationships with industry.
Contribution of each author
Conception and design of the analysis: MB, FS, MT, AS.
Interpretation of data: MB, AS, AB.
Drafting of the manuscript: MB, AS.
Revision and Final Approval: FS, MT, AB, JS, WH, HM, AW, MC, CT, HH, AS.
Acknowledgment
None.
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