Background

Atrial Fibrillation (AF) and heart failure often co-exist and mutually increase cardiovascular morbidity and mortality. Pulmonary vein isolation (PVI) is effective and safe in this patient population and even reduces mortality. However, current class IA guideline recommendation for PVI exists only for patients with tachycardiomyopathy (tachyCM). In contrast PVI should only be considered (class IIC) in non-tachycardiomyopathy (non-tachyCM). In this context, data comparing efficacy and safety of PVI in tachyCM and non-tachyCM are lacking.

Methods

We prospectively analyzed consecutive AF patients with reduced left ventricular ejection fraction (LVEF) who underwent CryoPVI in a single-center cohort between 2018 and 2023. CryoPVI was performed in a standardized fashion. Follow-up was performed at 3, 6, and 12 months after CryoPVI. Endpoints were symptomatic AF relapse for efficacy and bleeding, phrenic nerve injury, stroke or death for safety. Periprocedural parameters were observed.

Results

During the study period 1068 patients underwent CryoPVI. Of these, 130 patients had reduced LVEF. TachyCM was present in 91 (70%) patients (age 71±9 years, CHA2DS2-VASc 3.2±1.4, LVEF 35± 6%) while 39 (30%) patients had non-tachyCM (age 68±12 years, CHA2DS2-VASc 3.6±1.5, LVEF 31±8%). After 12 months incidence of primary efficacy endpoint was similar in tachyCM and non-tachyCM patients (28% vs. 15.5%, p=0.14). Primary safety endpoint were occurred in form of phrenic nerve injury in one patient with tachy-CM (1.1%) and one non-tachyCM patient and death in one patient with non-tachyCM (5.1%). No strokes were observed in either group. Of interest, CryoPVI resulted in significantly greater improvement in LVEF in patients with tachyCM compared with non-tachyCM group. (15.8±9.2 % vs. 6.8±12%, p=0.0026, figure)

Conclusion

CryoPVI is equally safe and effective in patients with tachyCM and non-tachyCM. While etiology of heart failure has no influence on efficacy, there is a significant improvement in LVEF for patients with tachyCM compared to the non-tachyCM group.