Cryoballoon Ablation for the Treatment of Atrial Fibrillation in Patients With Concomitant Heart Failure and Either Reduced or Preserved Left Ventricular Ejection Fraction: Results From the Cryo AF Global Registry

Abstract

Background Heart failure (HF) and atrial fibrillation (AF) often coexist; yet, outcomes of ablation in patients with AF and concomitant HF are limited. This analysis assessed outcomes of cryoablation in patients with AF and HF. Methods and Results The Cryo AF Global Registry is a prospective, multicenter registry of patients with AF who were treated with cryoballoon ablation according to routine practice at 56 sites in 26 countries. Patients with baseline New York Heart Association class I to III (HF cohort) were compared with patients without HF. Freedom from atrial arrhythmia recurrence ≥30 seconds, safety, and health care utilization over 12-month follow-up were analyzed. A total of 1303 patients (318 HF) were included. Patients with HF commonly had preserved left ventricular ejection fraction (81.6%), were more often women (45.6% versus 33.6%) with persistent AF (25.8% versus 14.3%), and had a larger left atrial diameter (4.4±0.9 versus 4.0±0.7 cm). Serious procedure-related complications occurred in 4.1% of patients with HF and 2.6% of patients without HF (P=0.188). Freedom from atrial arrhythmia recurrence was not different between cohorts with either paroxysmal AF (84.2% [95% CI, 78.6-88.4] versus 86.8% [95% CI, 84.2-89.0]) or persistent AF (69.6% [95% CI, 58.1-78.5] versus 71.8% [95% CI, 63.2-78.7]) (P=0.319). After ablation, a reduction in AF-related symptoms and antiarrhythmic drug use was observed in both cohorts (HF and no-HF), and freedom from repeat ablation was not different between cohorts. Persistent AF and HF predicted a post-ablation cardiovascular rehospitalization (P=0.032 and P=0.001, respectively). Conclusions Cryoablation to treat patients with AF is similarly effective at 12 months in patients with and without HF. Registration URL: https://www.clinicaltrials.gov; Unique Identifier: NCT02752737.

Keywords: atrial fibrillation; catheter ablation; heart failure.

Figures

Figure 1. Baseline characteristics of the heart failure (HF) cohort.

The HF cohort stratified by New York Heart Association (NYHA) class status and left ventricular ejection fraction (LVEF). Patients had an NYHA class of I to III, and most patients had preserved LVEF. EF indicates ejection fraction; HFmEF, HF with mild reduced ejection fraction; HFpEF, heart failure with preserved ejection fraction; and HFrEF, heart failure with reduced ejection fraction.

Figure 2. Freedom from atrial arrhythmia recurrence over 12 months.

Kaplan–Maier estimate of 12‐month freedom from a ≥30‐second recurrence of atrial fibrillation (AF)/atrial flutter (AFL)/atrial tachycardia (AT) in patients with paroxysmal AF (blue) and persistent AF (red) with (dashed line) and without (solid line) heart failure (HF). Persistent AF at baseline predicted atrial arrhythmia recurrence (P<0.001), but HF status did not predict arrhythmia recurrence over the 12‐month follow‐up (P=0.319). PAF indicates paroxysmal atrial fibrillation; and PsAF, persistent atrial fibrillation.

Figure 3. Change in atrial fibrillation (AF)–related symptoms after cryoballoon ablation.

A, The percentage of patients with heart failure (HF) and patients without HF with 0 (green), 1 (blue), 2 (yellow), and ≥3 AF‐related symptoms (red) at baseline and 12‐month follow‐up is depicted. AF‐related symptom burden was higher in the HF cohort at baseline, and AF symptom burden significantly reduced from baseline to 12 months in both the HF and no‐HF cohorts (P<0.001). B, AF‐related symptoms after cryoballoon ablation were significantly reduced between baseline and the 12‐month follow‐up (P<0.001 for all except syncope in the HF group, P=0.052).

Figure 4. Health care utilization after cryoballoon ablation.

A, Antiarrhythmic drug utilization decreased between discharge (blue) and 12 months (yellow) among patient subgroups. B, Kaplan‐Meier estimate of freedom from reablation over 12 months is displayed. Persistent atrial fibrillation (AF), but not heart failure (HF) status (P=0.439), predicted reablation (P=0.001) over follow‐up. Kaplan–Meier estimates of (C) freedom from all‐cause and (D) cardiovascular‐related rehospitalization over 12‐month follow‐up are presented. HF predicted both all‐cause (P<0.001) and cardiovascular‐related (P<0.001) rehospitalization. Persistent AF did not predict all‐cause hospitalization (P=0.179) but did predict cardiovascular‐related rehospitalization (P=0.032) over follow‐up. AAD indicates antiarrhythmic drug; PAF, paroxysmal atrial fibrillation; and PsAF, persistent atrial fibrillation.