Efficacy and limitation of nonparoxysmal atrial fibrillation ablation in patients with heart failure with preserved ejection fraction

Abstract Introduction Catheter ablation for atrial fibrillation (AF) reduces heart failure (HF) hospitalization in patients with HF with preserved ejection fraction (HFpEF). However, the long‐term outcomes and subclinical HF after nonparoxysmal AF ablation in HFpEF patients have not been fully evaluated. Methods and Results One‐hundred‐ninety nonparoxysmal AF patients with left ventricular ejection fraction ≥50% who underwent first‐time AF ablation were studied. HFpEF was diagnosed from a history of congestive HF and/or combined criteria of N‐terminal pro‐brain natriuretic peptide (NT‐proBNP) concentration and transthoracic echocardiogram parameters, including average septal‐lateral E/e' and tricuspid regurgitation peak velocity. Ninety‐five patients with HFpEF (HFpEF group) were compared with 95 patients without HF (CNT group). Low voltage area (LVA) was defined as an area with a bipolar electrogram of <0.5 mV covering >5% of the total left atrial surface. The primary endpoint was a composite of death from any cause or hospitalization for worsening HF. The secondary endpoint was subclinical HFpEF defined from NT‐proBNP concentration and average septal‐lateral E/e' or tricuspid regurgitation peak velocity at 6–12 months after the procedure irrespective of the rhythm. Kaplan–Meier curves showed that the primary composite endpoint did not differ between the two groups (mean follow‐up period 707 ± 75 days, log‐rank p = 0.5330). However, significantly more patients in the HFpEF group reached the secondary endpoint (42 [44%] vs. 13 [14%], p < 0.0001). Multivariate analysis revealed that a high preablation NT‐proBNP (odds ratio [OR] 1.001, 95% confidence interval [CI] 1.001–1.002, p = 0.0040) and the existence of LVA (OR 5.983, 95% CI 1.463–31.768, p = 0.0194) independently predicted the secondary endpoint in HFpEF patients. Conclusion After nonparoxysmal AF ablation, mortality of HFpEF patients was not inferior compared to patients without coexisting HF. However, subclinical HF occasionally persisted especially in HFpEF patients with a high preprocedure NT‐proBNP concentration and LVA.