Interventional rhythm control is associated with an improved long-term prognosis of patients with atrial fibrillation undergoing transcatheter edge-to-edge mitral valve repair
Authors: Waechter C , Chatzis G , Mueller J , Barth S , Halbfass P , Deneke T , Kerber S , Fischer D , Nef H , Mueller H H , Schieffer B , Divchev D , Luesebrink U , Ausbuettel F 
Published: November 2023

Abstract

Background
Atrial fibrillation (AF) is the most common concomitant disease in patients undergoing transcatheter edge-to-edge repair (TEER) for severe mitral regurgitation (MR) and detrimentally affects their long-term survival. While the prognostic improvement of catheter ablation (CA) of AF in the overall cohort of heart failure (HF) patients as well as that of surgical ablation of AF with concomitant MR surgery are well established, data on the outcomes of CA of AF in TEER patients are lacking.

Methods
In a multicenter retrospective observational cohort study, consecutive patients undergoing TEER were enrolled and long-term survival of patients receiving catheter ablation (CA) for AF was compared with that of patients on pharmacological AF treatment and with that of patients without a history of AF, using propensity score matching and multivariable Cox regression analyses.

Results
A total of 821 patients were identified who successfully underwent TEER procedure. Within this cohort, 608 (74.1%) had concomitant AF, of which 48 patients received CA. Patients with CA of AF showed significantly higher cumulative survival 5 years after the TEER procedure compared with propensity score-matched patients on pharmacological rhythm control of AF (64.6% [31/48] vs. 33.3% [64/192], p=0.01) or on rate control of AF (64.6% [31/48] vs. 25.0% [24/96], p=0.0015). Multivariable Cox regression analysis confirmed that CA of AF was independently associated with significantly better long-term outcome than pharmacological rhythm control and rate control of AF (hazard ratio [HR] 0.4, 95%-confidence interval [CI] 0.2-0.9, p=0.02 and HR 0.4, 95%-CI 0.2-0.7, p=0.004, respectively). CA even offsets the prognostic disadvantage of coexisting AF, as the cumulative survival 5 years after TEER intervention is not significantly different from propensity score-matched TEER patients without a history of AF (64.6% [31/48] vs. 38.9% [56/144], p=0.3).

Conclusion
Using established statistical methods of propensity score matching and multivariable Cox regression, we demonstrate a significantly improved long-term outcome of TEER patients undergoing CA of concomitant AF compared with pharmacological AF management. CA even offsets the prognostic disadvantage of coexisting AF, as the outcome is not significantly different from that of TEER patients without a history of AF. In light of the growing evidence of prognostic benefit and safety of CA of AF in the overall cohort of HF patients, our data, albeit not randomized, provide strong evidence for interventional rhythm control of AF as an essential part of a modern and holistic management of TEER patients. We alert to the importance of treating concomitant AF, as this is a very promising approach to improve the prognosis of this unique and continually growing HF population.Flow chart of the study designSurvival analyses of PSM cohorts