Different approaches to atrial fibrillation ablation in heart failure patients: temporal trends and clinical outcomes

Abstract Background Catheter ablation of atrial fibrillation (AF) has been proven beneficial in patients with heart failure and reduced ejection fraction (HFrEF). On top of pulmonary vein isolation (PVI), additional ablation strategies (PVI+) are often used in HFrEF patients. Whether PVI+ provides additional benefits in this population has never been systematically investigated. Objectives To analyze the temporal trends and comparative outcomes of PVI+ vs. PVI-alone. Methods Patients with HFrEF undergoing AF ablation were retrospectively enrolled. The two co-primary endpoints were ventricular function recovery and AF recurrence-free survival at one year. The performance of PVI and PVI+ was compared in the overall population and in two matched groups. A sensitivity analysis for measured confounders was performed. Results A total of 955 HFrEF patients (62.1 years, 24.4% females) from 9 international centers were included (PVI-only 51.6% vs PVI+ 48.4%). At 12 months after the procedure, 62.3% of the patients remained free from arrhythmia recurrences and 65.4% experienced ventricular function recovery. Comparing PVI to PVI+, no significant difference in the two co-primary endpoints was observed, neither in the overall nor in the matched cohorts. The use of PVI+ increased from 27% in 2013 to 68% in 2022. Patients undergoing PVI+ experienced more complications (3.8 vs 1.2%, p=0.018). Conclusions Catheter ablation is associated with significant improvements in systolic function, irrespective of the ablation strategy used. The use of PVI+ in HFrEF patients is progressively expanding over time. Although the benefits of this practice remain unproven, it is associated with an increased risk of complications. These results warrant caution regarding the growing use of PVI+ in HFrEF patients.