The Role of Posterior Wall Isolation in Catheter Ablation for Persistent Atrial Fibrillation and Systolic Heart Failure
Authors: William Jeremy , Chieng David , Sugumar Hariharan , Ling Liang-Han , Segan Louise , Crowley Rose , Al-Kaisey Ahmed , Hawson Joshua , Prabhu Sandeep , Voskoboinik Aleksandr , Wong Geoffrey , Morton Joseph B. , Lee Geoffrey , McLellan Alex J. , Wong Michael , Pathak Rajeev K. , Sterns Laurence , Ginks Matthew , Reid Christopher M. , Sanders Prashanthan , Kalman Jonathan M. , Kistler Peter M. 
Published: September 2023

ImportanceCatheter ablation for patients with atrial fibrillation (AF) and heart failure with reduced ejection fraction (HFrEF) is associated with improved left ventricular ejection fraction (LVEF) and survival compared with medical therapy. Nonrandomized studies have reported improved success with posterior wall isolation (PWI).ObjectiveTo determine the impact of pulmonary vein isolation (PVI) with PWI vs PVI alone on outcomes in patients with HFrEF.Design, Setting, and ParticipantsThis was an ad hoc secondary analysis of the CAPLA trial, a multicenter, prospective, randomized control trial that involved 11 centers in 3 countries (Australia, Canada, and UK). CAPLA featured 338 patients with persistent AF randomized to either PVI plusPWI or PVI alone. This substudy included patients in the original CAPLA study who had symptomatic HFrEF (LVEF &amp;lt;50% and New York Heart Association class ≥II).InterventionsPulmonary vein isolation with PWI vs PVI alone.Main Outcomes and MeasuresThe primary end point was freedom from any documented atrial arrhythmia greater than 30 seconds, after a single ablation procedure, without the use of antiarrhythmic drug (AAD) therapy at 12 months.ResultsA total of 98 patients with persistent AF and symptomatic HFrEF were identified (mean [SD] age, 62.1 [9.8] years; 79.5% men; and mean [SD] LVEF at baseline, 34.6% [7.9%]). After 12 months, 58.7% of patients with PVI plus PWI were free from recurrent atrial arrhythmia without the use of AAD therapy vs 61.5% with PVI alone (hazard ratio, 1.02; 95% CI, 0.54-1.91; P = .96). There were no significant differences in freedom from atrial arrhythmia with or without AAD therapy after multiple procedures (PVI plus PWI vs PVI alone, 60.9% vs 65.4%; P = .73) or AF burden (median, 0% in both groups; P = .78). Mean LVEF improved substantially in PVI plus PWI (∆ LVEF, 19.3% [13.0%; P &amp;lt; .01) and PVI alone (18.2% [14.1%; P &amp;lt; .01), with no difference between groups (P = .71). Normalization of LV function occurred in 65.2% of patients in the PVI plus PWI group and 50.0% of patients with PVI alone (P = .13).Conclusions and RelevanceThe results of this study indicate that addition of PWI to PVI did not improve freedom from arrhythmia recurrence or recovery of LVEF in patients with persistent AF and symptomatic HFrEF. Catheter ablation was associated with significant improvements in systolic function, irrespective of ablation strategy used. These results caution against the routine inclusion of PWI in patients with HFrEF undergoing first-time catheter ablation for persistent AF.Trial Registrationhttp://anzctr.org.au Identifier: ACTRN12616001436460