Pulsed field ablation for atrial fibrillation in patients with heart failure: insight from the ATHENA registrys

Aims: Data on pulsed-field ablation (PFA) for atrial fibrillation (AF) in patients with heart failure (HF) are limited. To evaluate clinical outcomes of PFA in patients with AF and HF, stratified by HF subtype. Methods and results: Consecutive patients undergoing first-time pentaspline PFA within the ATHENA registry were analyzed. Patients were stratified into three groups: no HF, HF with preserved ejection fraction (HFpEF, LVEF ≥50%), and HF with mildly reduced or reduced EF (HFmrEF/rEF, LVEF <50%). The primary endpoint was freedom from documented atrial arrhythmias >30 s after a 2-month blanking period. AAD use was left to physician discretion. Among 1,224 patients included (68.5% with paroxysmal AF and 31.5% with persistent AF), 176 (14.4%) had HF: 40 (3.3%) with HFpEF and 136 (11.1%) with HFmrEF/rEF. The Kaplan-Meier estimated freedom from any atrial arrhythmias at 1-year follow-up was 79.9%, with higher rate in the no-HF group (81.0%) vs the HF group (73.3%, HR = 1.5, 95% CI: 1.1-2.1, P = 0.0133). Considering separately paroxysmal and persistent AF form, paroxysmal AF patients with no sign of HF showed significantly higher freedom from atrial arrhythmias (82.2%) than patients with HF (68.6%, 2.0, 1.3-3.1, P = 0.0028), while no differences were found in patients with persistent AF (77.9% vs 76.4%, 1.1, 0.7-1.7, P = 0.7065). Conclusion: PFA with the pentaspline catheter appears to be an effective treatment for AF in patients with HF. Freedom from AF and atrial arrhythmias post-PFA was highest in patients with paroxysmal AF and no history of HF, with no significant differences observed in persistent AF patients. Clinical trial registration: Advanced TecHnologies For SuccEssful AblatioN of AF in Clinical Practice (ATHENA). URL: http://clinicaltrials.gov/Identifier: NCT05617456.