Is catheter ablation a suitable treatment option for patients with Heart Failure with preserved Ejection Fraction (HFpEF) and atrial fibrillation?

Catheter Ablation for Atrial Fibrillation in Patients with HFpEF

Catheter ablation should be considered as a treatment option for patients with atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF), particularly in symptomatic patients where rhythm control is desired. 1

Current Evidence and Recommendations

The management of AF in patients with HFpEF presents unique challenges due to the complex bidirectional relationship between these conditions. While there is robust evidence supporting catheter ablation in heart failure with reduced ejection fraction (HFrEF), the evidence for HFpEF is emerging but promising.

Evidence for Catheter Ablation in HFpEF

• Recent observational studies show that catheter ablation in HFpEF patients:

  • Decreases heart failure hospitalization 2
  • Improves diastolic function 2
  • Reduces heart failure symptoms 2
  • May lead to HFpEF resolution in approximately 35% of treated patients (compared to only 9% with medical therapy alone) 2

• Meta-analyses demonstrate:

  • Long-term sinus rhythm achievement in 58% of HFpEF patients 3
  • Similar arrhythmia-free survival and safety profiles compared to patients with HFrEF or without heart failure 4

Patient Selection for Catheter Ablation

Careful patient selection is critical for optimal outcomes. Consider catheter ablation for HFpEF patients with:

• Recent onset AF with fast ventricular rates 1
• Younger age (<65 years) 1
• Left atrial diameter <55mm 1
• Symptomatic AF despite adequate rate control 5
• AF that is refractory to pharmacological rhythm control 5

Procedural Approach

The ablation strategy should be tailored to the individual patient's arrhythmogenic substrate:

• Pulmonary vein isolation (PVI) is the cornerstone of AF ablation 5
• Additional ablation strategies may be required in patients with:
  • Persistent or long-standing persistent AF
  • Advanced structural remodeling
  • Non-convertible AF following PVI 5

Management After Ablation

Post-ablation management is crucial for long-term success:

• Early recurrences (within the blanking period) can be managed with electrical cardioversion with or without antiarrhythmic drug support 5
• For patients who underwent ablation after failed pharmacological rhythm control, consider continuing amiodarone for 8-12 weeks post-procedure 5
• For late recurrences (>3 months), consider repeat ablation, particularly in patients who showed clinical benefit from the initial procedure 5

Ongoing Research

The CABA-HFPEF-DZHK27 trial is currently investigating whether early catheter ablation for AF can prevent adverse cardiovascular outcomes in patients with HFpEF or HFmrEF. This trial will provide more definitive evidence on the role of systematic and early catheter ablation in this patient population 6.

Potential Pitfalls and Caveats

• Complication rates of AF ablation in HFpEF patients are similar to those without heart failure, but careful pre-procedural assessment is essential 4
• Long-term success rates may be lower in patients with advanced structural remodeling 5
• Ablation should be performed in experienced centers with expertise in managing complex AF cases 5
• An AF Heart Team approach is recommended for complex cases, involving multidisciplinary discussion of treatment options 1

In conclusion, while the European Society of Cardiology guidelines provide more robust recommendations for catheter ablation in HFrEF patients (Class IIa-B), emerging evidence supports considering this approach in selected HFpEF patients with AF, particularly those who are symptomatic or refractory to medical therapy.