In this retrospective cohort study, we investigated the association between HFpEF and outcomes of CA for AF. The results are as follows: First, patients with HFpEF exhibited a lower rate of arrhythmia-free survival after ablation for AF than did those without HF at 12 months. Second, the symptom severity of patients with HFpEF was significantly reduced, as indicated by the EHRA score after CA. Third, no significant increase was noted in all-cause hospitalizations between the HFpEF and non-HF groups. These results suggest that CA can serve as an effective treatment method for patients with HFpEF, despite a higher risk of atrial arrhythmia recurrence than in those without HF.
While several studies have evaluated HFpEF as a risk factor for AF recurrence after CA, the results have been inconsistent. In our present study, HFpEF was found to independently increases the risk of atrial arrhythmia recurrence. Patients with HFpEF exhibited significantly lower arrhythmia-free survival rates than those without HF following a 12-month observation period. This finding aligns with the findings of a recent single-center prospective and observational study (n = 79), which revealed an association between HFpEF and elevated rates of atrial arrhythmia recurrences after a median 12-month follow-up [20]. The results of our present study indicate that HFpEF could increase the recurrence rate of atrial arrhythmia, a conclusion supported by the consistent findings. Previous studies have shown that diastolic failure may lead to recurrence of AF post-radiofrequency CA [21, 22]. In patients with AF, HF increases ventricular pressure, resulting in an increase in atrial wall pressure, promoting left atrial fibrosis, and leading to atrial remodeling through pathological and physiological mechanisms such as calcium-handling abnormalities or neurohormone and adrenergic receptor activation [23, 24]. These factors may also contribute to AF progression.
Compared to our study, a retrospective cohort study of 547 patients undergoing CA for AF revealed no notable difference in arrhythmia recurrence, irrespective of the use of antiarrhythmic drugs. This was observed after median tracking periods of 50.9 and 31.3 months for the HFpEF and non-HF groups, respectively (P = 0.027) [25]. Consequently, the disparity in these findings could stem from the distinctive follow-up durations or discrepancies in the populations studied.
A single-center prospective study using invasive hemodynamic measurements showed that CA for AF may enhance the living quality of patients with HFpEF (n = 35) [26], similar to the findings of our study. Another retrospective cohort analysis involving 547 patients similarly observed no significant difference in all-cause hospitalization rates (adjusted HR: 2.05; 95% CI: 1.30–3.23) between the HFpEF and non-HF groups [25]. Further, a previous study assessing the 12-month post-ablation outcomes reported resolution of HFpEF in 42.9% and 51% of patients after their initial ablation procedure and after several procedures, respectively. These findings suggest a possible causal relationship. HFpEF resolution was closely related to the freedom from recurrence of arrhythmia post-ablation [27]. Previous studies have shown that AF can induce and exacerbate HF. In AF, the heart rate increases, and the left ventricular end-diastolic filling time decreases, resulting in loss of atrial systolic ability and consequently causing a decrease in cardiac output and activation of neurohormones. In addition, some studies have demonstrated that the rapid ventricular rate can exacerbate the decline in left ventricular function, leading to tachycardiomyopathy and facilitating the occurrence of HF [23, 28]. Therefore, patients with HFpEF should theoretically benefit from CA. These findings hold significant implications. While the effectiveness of ablation in patients with AF and HFrEF has been established in terms of maintaining sinus rhythm, enhancing the quality of life, and decreasing hospitalization rates [29, 30], whether these advantages also apply to patients with HFpEF remains uncertain. The present study showed that despite the less favorable HFpEF-related outcomes, CA reduced the burden of AF-related symptoms. However, the potential benefits of CA in patients with HFpEF remain unclear.
This study has some limitations. First, this retrospective, single-center observational study was limited by its relatively short follow-up period and small sample size. Second, the EHRA grading method is relatively simple, which may cause some errors in grading the severity of AF symptoms. Third, external factors such as mood swings, staying up late, climate change, and lifestyle change can also contribute to the difference in recurrence time, and this study did not account for the effect of potential inducement. Finally, due to a lack of standard equipment for detecting atrial arrhythmias, including an implantable loop monitor, the recurrence of some asymptomatic AF may be overlooked. Therefore, comprehensive, prospective, randomized clinical trials that focus on outcomes of CA for AF in patients with HFpEF are required to establish the effects of ablation on HFpEF outcomes.