Ablate and Pace Versus Pulmonary Vein Isolation in Patients with Atrial Fibrillation and Heart Failure

Purpose: Atrial fibrillation (AF) is common in patients with severe heart failure (HF). Catheter ablation can be utilized via either atrioventricular node (AVN) ablation with biventricular pacing or pulmonary vein isolation (PVI) for patients who are refractory or intolerant to pharmacotherapy. The purpose of the study is to assess outcomes of AVN ablation with biventricular pacing versus PVI in patients with AF and severe HF.

Material and Methods: We identified patients with AF and severe HF, defined as ejection fraction ≤ 40%, ACC/AHA stage C or D and NYHA class II to IV, who underwent AVN ablation with biventricular pacing or PVI at UC San Diego between 2012 and 2019. We compared the procedural and clinical outcomes between the two ablation strategies.

Results: Of 129 patients who met criteria, 56 patients had AVN ablation and 73 patients had PVI. Predictors of AVN ablation include older age (OR 1.11, 95% CI 1.01-1.23, p = 0.027), NYHA class III/IV (OR 16.68, 95% CI 1.20-232.30, p = 0.036), and concurrent guideline-based indication for CRT (OR 103.93, 95% CI 3.31-3265.69, p = 0.008). Both AVN ablation and PVI were associated with improvement in ejection fraction (25.9% vs 35.0%, p < 0.001 and 31.3% vs 46.2%, p < 0.001, respectively). In crude analysis, PVI was associated with increased 2-year survival and decreased HF hospitalization compared to AVN ablation (Figure). After multivariable adjustment, there was a trend towards higher mortality with AVN ablation (HR 4.33, 95% CI 0.94-19.93, p = 0.06).

Conclusions: AVN ablation with biventricular pacing and PVI are appropriate ablation strategies in patients with AF and advanced HF. Patients who underwent PVI had a trend towards better survival at 2 years.