Original Article
Catheter Ablation of Atrial Fibrillation in Patients with Concomitant Left Ventricular Impairment: a Systematic Review of Efficacy and Effect on Ejection Fraction

https://doi.org/10.1016/j.hlc.2014.09.012Get rights and content

Introduction

Catheter ablation of atrial fibrillation (AF) is an established rhythm control strategy; however, the impact of co-existing LV systolic dysfunction (LVSD) on ablation success is less well understood. This systematic review compiles the outcomes of catheter ablation of atrial fibrillation in patients with LVSD.

Methods

An electronic database (Pubmed, Scopus, Embase) search using the keywords ‘atrial fibrillation AND ablation AND (ventricular dysfunction OR heart failure OR cardiomyopathy)’ was performed for English scientific literature up to 01/01/2014. 2484 references were retrieved and evaluated for relevance by three reviewers. Reviews and reference lists of retrieved articles were also examined to ensure all relevant studies were included. Data was extracted from 19 studies, including a total of 914 patients.

Results

Single-procedure success in LVSD patients for AF ablation was 56.5% (95% CI: 48%-64%). Overall multiple-procedure (including the use of anti-arrhythmic drugs) in LVSD patients for AF ablation was 81.8% (95% CI: 75%-87%). The mean increase in LVEF following AF ablation was 13.3% (95% CI: 10.8%-15.9%). Seven studies reported improvements in exercise capacity and quality of life information using standardised criteria. The pooled rate of serious adverse events was 5.5% (95% CI: 3.7%-8.1%).

Conclusions

Catheter ablation may be an effective therapy in AF patients with left ventricular systolic impairment, and can be associated with improvements in left ventricular function, quality of life, exercise capacity, and modest rates of serious adverse events.

Introduction

Heart failure (HF) and atrial fibrillation (AF) are intricately coupled clinical conditions. AF is common amongst HF patients, and is particularly prevalent in patients with higher NYHA functional class [1]. At least one in four newly-diagnosed AF patients may suffer from HF, and the development of AF in HF patients represents a significant risk factor for mortality [2], [3].

In the past decade, catheter ablation has become established as a therapy for symptomatic, drug-refractory AF [4], [5]. Current guidelines cautiously support AF ablation for patients with co-existent left ventricular impairment, suggesting that AF ablation may be considered in selected symptomatic patients with HF and/or reduced ejection fraction [4], [5].

As such, the role of catheter ablation in AF patients with concomitant LVSD is not only an area of uncertainty, but an important management issue in the care of HF patients. There has recently been a significant increase in the number of studies reporting clinical outcomes in AF and HF. The primary purpose of our study was to evaluate the efficacy and safety of AF ablation LVSD patients, as well as the impact of AF ablation on left ventricular ejection fraction (LVEF) and quality of life (QOL).

Section snippets

Methods

We searched the scientific literature in PubMed, Scopus, Embase, using the search terms “atrial fibrillation AND ablation AND (ventricular dysfunction OR heart failure OR cardiomyopathy)”. This search was supplemented by hand-searching of bibliographies and narrative reviews of AF and HF. The primary criterion for inclusion were studies reporting outcomes for percutaneous catheter ablation outcomes of AF in HF patients. Criteria for left ventricular systolic dysfunction case definition were

Search and Synthesis of Literature

2484 unique citations were identified. 2333 were excluded on general criteria, and 151 were selected for detailed secondary review. From this group, a total of 19 publications met inclusion criteria. Included studies were published between 2004-2014.

Study Design and Characteristics

Study quality was limited in that the majority of studies were non-randomised, including single centre case series [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], with four randomised control trials [21], [22], [23],

Discussion

Catheter ablation has become an established therapy for the treatment of symptomatic AF [4]. However, the role of AF ablation in the management of patients with co-existent left ventricular systolic dysfunction is an area of uncertainty. We performed a systematic review of the published literature to assess the outcomes of catheter ablation in patients with comorbid AF and LVSD.

We found that:

  • AF ablation is able to restore sinus rhythm in LVSD patients, with satisfactory single procedure and

Disclosures

Sources of Funding: Dr Ganesan is supported by an Australian Early Career Health Practitioner Fellowship of the National Health and Medical Research Council of Australia. Dr Pathak and Twomey are supported by Leo J. Mahar Electrophysiology Scholarships from the University of Adelaide. Dr Mahajan is supported by the Leo J. Mahar Lectureship from the University of Adelaide. Dr Lau is supported by a Postdoctoral Fellowship from the National Health and Medical Research Council of Australia. Dr

Conflicts of Interest

Dr Sanders reports having served on the advisory board of Biosense-Webster, Medtronic, St Jude Medical, Sanofi-Aventis and Merck, Sharpe and Dohme. Dr Sanders reports having received lecture and/or consulting fees from Biosense-Webster, Medtronic, St Jude Medical, Boston Scientific, Merck, Sharpe and Dohme, Biotronik and Sanofi-Aventis. Dr Sanders reports having received research funding from Medtronic, St Jude Medical, Boston Scientific, Biotronik and Sorin.

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