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