Segan Louise, Chieng David, Sugumar Hariharan, Voskoboinik Aleksandr, Ling Liang-Han, Costello Ben, Azzopardi Sonia, Nderitu Ziporah, Parameswaran Ramanathan, Amerena John, McLellan Alex J, Lee Geoffrey, Morton Joseph, Joseph Stephen, Wong Michael, Taylor Andrew, Kalman Jonathan M, Kistler Peter M, Prabhu Sandeep
The Baker Heart and Diabetes Research Institute, Melbourne, Australia.
The Alfred Hospital, Melbourne, Australia.
J Cardiovasc Electrophysiol. 2023 Oct;34(10):2065-2075. doi: 10.1111/jce.16052. Epub 2023 Sep 11.
The absence of ventricular scar in patients with atrial fibrillation (AF) and systolic heart failure (HF) predicts left ventricular (LV) recovery following AF ablation. It is unknown whether age impacts the degree of LV recovery, reverse remodeling, or AF recurrence following catheter ablation (CA) among this population.
To evaluate the impact of age on LV recovery and AF recurrence in a population with AF and systolic HF without fibrosis (termed AF-mediated cardiomyopathy) following CA.
Consecutive patients undergoing CA between 2013 and 2021 with LV ejection fraction (LVEF) < 45% and absence of cardiac magnetic resonance imaging (CMR) detected LV myocardial fibrosis were stratified by age (<65 vs. ≥65 years). Following CA, participants underwent remote rhythm monitoring for 12 months with repeat CMR for HF surveillance.
The study population consisted of 70 patients (10% female, mean LVEF 33 ± 9%), stratified into younger (age < 65 years, 63%) and older (age ≥ 65 years, 37%) cohorts. Baseline comorbidities, LVEF (34 ± 9 vs. 33 ± 8 ≥65 years, p = .686), atrial and ventricular dimensions (left atrial volume index: 55 ± 21 vs. 56 ± 14 mL/m age ≥ 65, p = .834; indexed left ventricular end-diastolic volume: 108 ± 40 vs. 104 ± 28 mL/m age ≥ 65, p = .681), pharmacotherapy and ablation strategy (pulmonary vein isolation in all; posterior wall isolation in 27% vs. 19% age ≥ 65, p = .448; cavotricuspid isthmus in 9% vs. 11.5% age ≥ 65) were comparable (all p > .05) albeit a higher CHADS VASc score in the older cohort (2.7 ± 0.9 vs. 1.6 ± 0.6 age < 65, p < .001). Freedom from AF was comparable (hazard ratio: 0.65, 95% confidence interval: 0.38-1.48, LogRank p = .283) as was AF burden [0% (interquartile range, IQR: 0.0-2.1) vs. age ≥ 65: [0% (IQR 0.0-1.7), p = .516], irrespective of age. There was a significant improvement in LV systolic function in both groups (ΔLVEF + 21 ± 14% vs. +21 ± 12% age ≥ 65, p = .913), with LV recovery in the vast majority (73% vs. 69%, respectively, p = .759) at 13 (IQR: 12-16) months. This was accompanied by comparable improvements in functional status (New York Heart Association class p = .851; 6-min walk distance 50 ± 61 vs. 93 ± 134 m in age ≥ 65, p = .066), biomarkers (ΔN-terminal-pro brain natriuretic peptide -139 ± 246 vs. -168 ± 181 age ≥ 65,p = .629) and HF symptoms (Short Form-36 survey Δphysical component summary p = .483/Δmental component summary, p = .841).
In patients undergoing CA for AF with systolic HF in the absence of ventricular scar, comparable improvements in ventricular function, symptoms, and freedom from AF are achieved irrespective of age.
心房颤动（AF）合并收缩性心力衰竭（HF）患者无心室瘢痕预示着AF消融术后左心室（LV）功能恢复。目前尚不清楚年龄是否会影响该人群经导管消融（CA）后的LV恢复程度、逆向重构或AF复发情况。
评估年龄对CA治疗的AF合并收缩性HF且无纤维化（称为AF介导的心肌病）患者LV恢复和AF复发的影响。
对2013年至2021年间接受CA治疗、左心室射血分数（LVEF）<45%且心脏磁共振成像（CMR）未检测到LV心肌纤维化的连续患者，按年龄（<65岁与≥65岁）分层。CA术后，参与者接受12个月的远程心律监测，并重复CMR以监测HF。
研究人群包括70例患者（10%为女性，平均LVEF 33±9%），分为较年轻（年龄<65岁，63%）和较年长（年龄≥65岁，37%）两组。基线合并症、LVEF（34±9与33±8≥65岁，p = 0.686）、心房和心室大小（左心房容积指数：55±21与56±14 mL/m年龄≥65，p = 0.834；左心室舒张末期容积指数：108±40与104±28 mL/m年龄≥65，p = 0.681）、药物治疗和消融策略（均行肺静脉隔离；后壁隔离在<65岁组为27%，≥65岁组为19%，p = 0.448；三尖瓣峡部隔离在<65岁组为9%，≥65岁组为11.5%）具有可比性（所有p>0.05），尽管较年长组的CHADS VASc评分更高（2.7±0.9与<65岁组的1.6±0.6，p<0.001）。AF复发率具有可比性（风险比：0.65，95%置信区间：0.38 - 1.48，LogRank p = 0.283），AF负荷也具有可比性[<65岁组为0%（四分位间距，IQR：0.0 - 2.1）与≥65岁组为[0%（IQR 0.0 - 1.7），p = 0.516]，与年龄无关。两组LV收缩功能均有显著改善（ΔLVEF +21±14%与≥65岁组的+21±12%，p = 0.913），在13（IQR：12 - 16）个月时绝大多数患者（分别为73%与69%，p = 0.759）实现LV恢复。同时，功能状态（纽约心脏协会分级p = 0.851；6分钟步行距离<65岁组为50±61米，≥65岁组为93±134米，p = 0.066）、生物标志物（ΔN末端脑钠肽前体 -139±246与≥65岁组的 -168±181，p = 0.629）和HF症状（简明健康状况调查Δ身体成分总结p = 0.483/Δ精神成分总结，p = 0.841）也有类似改善。
在无心室瘢痕的AF合并收缩性HF患者中，无论年龄大小，CA术后心室功能、症状及AF复发情况的改善程度均具有可比性。
