Effect of early pulmonary vein isolation in patients with heart failure and reduced ejection fraction

FUNDING ACKNOWLEDGEMENTS: Type of funding sources: None. BACKGROUND: Atrial fibrillation (AF) and heart failure (HF) often coexist leading to worse outcomes compared to AF or HF alone. According to the current guidelines, PVI as first-line therapy should be considered, however, the optimal timing of the procedure is still unknown. PURPOSE: We aimed to investigate the effect of early PVI on all-cause mortality and AF recurrence in patients with HFrEF. METHODS: We analyzed the data of 162 patients with symptomatic paroxysmal or persistent AF and heart failure with LVEF < 50% who underwent pulmonary vein isolation between 2010 and 2022. The patients’ medical history, laboratory results, echocardiographic and periprocedural parameters were collected in a structured registry. Early PVI was defined as catheter ablation performed within 12 months of AF diagnosis. The median follow-up was 59.7 months, the minimum follow-up was 12 months. Our primary endpoints were AF recurrence after a 3 months blanking period and all-cause mortality at any time during follow-up. RESULTS: Among the 162 patients, 77 experienced AF recurrence and 39 patients died during the follow-up period. The median age was 63.2 years. The median LVEF was 40% for early PVI and 37% for deferred PVI. Out of the 63 patients who underwent early PVI, 33 (52%) were taking amiodarone. Patients who underwent early PVI had longer freedom from recurrence (median 833 days until recurrence for early PVI, median 696 days for deferred PVI). Early PVI was a predictor of AF recurrence (HR: 0.58 [0.32-0.94], p=0.029).Early ablation was not associated with mortality benefit. However, among those who experienced AF recurrence, repeated ablation was associated with better survival during univariate Cox regression (p=0.01). Furthermore, in multivariate model, reablation was shown to be protective of mortality (HR: 0.312 [0.113-0.865], p=0.025) in the whole cohort. CONCLUSIONS: Our study shows that early rhythm control therapy with catheter ablation is more successful compared to deferred PVI in patients with AF and HFrEF. A redo-PVI was associated with better survival, thus a repeat ablation should be considered in case of arrhythmia recurrence in patients with AF and HF to reduce mortality.