AF Associated with Heart Failure
The co-mingling of heart failure and AF was examined in a review of patients in the Framingham Heart Study enrolled between 1980 and 2012.33 More than half of those with heart failure also had AF, typically with AF preceding rather than following heart failure. Of those with AF, more than a third had heart failure, which typically developed after the onset of AF. Regardless of the temporality between the two conditions, the increased morbidity and mortality when present together is increased compared to individual diagnoses.34Patients in heart failure with a reduced ejection fraction and concurrent AF have had also had low success with medical therapy including AADs and rate control medications. CASTLE-AF showed that catheter ablation for patients with paroxysmal or persistent AF, HF, and left ventricular dysfunction significantly lowered composite death and hospitalizations, improved left ventricular ejection fraction, and reduced AF burden compared to medical therapy. However, the patient population in the trial was highly selected, which potentially limits the applicability to real world practice.35,36Patients with LVEF <40% were excluded from CONVERGE and the mean LVEF in the Hybrid Convergent arm was 55%. Thus, patients with reduced LVEF were thought to be out of bounds for Hybrid convergent treatment. However, recently there has been interest in determining if a hybrid approach could successfully treat AF and subsequently improve LVEF in patients with reduced LVEF at baseline. Our multi-center retrospective analysis of patients included those presenting with severely reduced baseline LVEF (≤40%) and showed significantly improved LVEF after Hybrid Convergent treatment. Kiankhooy et al. used a thoracoscopic hybrid approach for patients with depressed EF and tachycardia mediated cardiomyopathy, which demonstrated feasibility and significantly improved ejection fraction after treatment at a mean of 3.5 years (±1.9 years) follow-up and improvement in NYHA Class from baseline.37