Impact of sinus rhythm maintenance after repeat catheter ablation on clinical outcomes in heart failure with preserved ejection fraction.

Background: Atrial fibrillation (AF) and heart failure (HF) with preserved ejection fraction (HFpEF) frequently coexist and significantly contribute to morbidity and mortality. Catheter ablation (CA) for AF in HFpEF patients can improve clinical outcomes compared to medical therapy. However, the impact of repeat (Re) CA for AF recurrence (AFR) in HFpEF patients on adverse events remains unclear. This study aimed to evaluate the impact of sinus rhythm maintenance (SRM) versus AFR after ReCA on clinical adverse outcomes and HFpEF improvement.

Methods: This retrospective study included 79 patients with AFR and HFpEF who underwent ReCA. HFpEF was defined as an HFA-PEFF score of 5-6 and left ventricular ejection fraction ≥50 %. HFpEF improvement was defined as a reduction in the 12-month HFA-PEFF score to 0-4. Patients were divided into two groups based on rhythm status after ReCA: SRM (post-ReCA SRM, n = 54) and AFR (post-ReCA AFR, n = 25). The primary endpoint was a composite of all-cause mortality, HF hospitalizations, or stroke during a 3-year follow-up. Secondary endpoints included 12-month HFA-PEFF scores and the proportion of patients with HFpEF improvement (HFA-PEFF score 0-4).

Results: The post-ReCA SRM group had a significantly lower incidence of the primary endpoint (7.4 % vs. 36 %, p = 0.002) and higher event-free survival (hazard ratio: 0.19, 95 % CI: 0.06-0.63, p = 0.006). The post-ReCA SRM group also showed lower 12-month HFA-PEFF scores [4 (3, 5) vs. 5 (4, 6), p = 0.045] and greater HFpEF improvement (48 % vs. 11 %, p = 0.005).

Conclusions: In HFpEF patients with AFR after initial CA, SRM after ReCA is significantly associated with fewer adverse events, including all-cause mortality, hospitalizations for worsening HF, and strokes, during a 3-year follow-up period, and improved HFpEF status during a 3-year follow-up.