Ablation Versus Medical Management of Atrial Fibrillation in HFpEF

  • STATUS
    Recruiting
  • End date
    Jan 29, 2025
  • participants needed
    60
  • sponsor
    Johns Hopkins University
Updated on 19 February 2024
heart disease
hypertrophy
heart failure
ejection fraction
diuretics
left ventricular hypertrophy
atrial fibrillation
ventricular hypertrophy
nt-probnp
b-type natriuretic peptide
natriuretic peptide
pro-brain natriuretic peptide
left ventricular end-diastolic pressure
diuretic therapy
persistent atrial fibrillation
fibrillation
cardioversion
holter monitor
pulmonary vein isolation
paroxysmal atrial fibrillation
pro b

Summary

This is a prospective non-blinded randomized control pilot study comparing the effect of pulmonary vein isolation against medical management of atrial fibrillation in patients with Heart Failure with preserved Ejection Fraction (HFpEF).

Description

Recent studies using PVI for rhythm control in patients with heart failure with reduced ejection fraction (HFrEF) have shown improvement in systolic ejection fraction, exercise capacity, quality of life, and a significant reduction in all-cause mortality. The PVI procedure has been shown to be safe and comparably effective in treating Atrial Fibrillation (AF) in HFpEF patients, but no studies have yet demonstrated the effects of catheter ablation on exercise capacity or clinical outcomes.

The investigators propose a prospective, non-blinded randomized control pilot study to assess the feasibility of conducting larger scale studies to determine if there are differences between catheter ablation with medical management on exercise capacity and quality of life in HFpEF patients with AF. The investigators' study will be powered for AF burden reduction, and the investigators hope to use the effect size on exercise capacity and heart failure events to help determine power for larger clinical studies that will follow to shed light on how invasive management of atrial fibrillation may impact the natural history of individuals with these two cardiovascular conditions.

Details
Condition Arrhythmia, Arrhythmia, Atrial Fibrillation, Atrial Fibrillation, Heart Failure With Normal Ejection Fraction
Age 18-90 years
Treatment Pulmonary Vein Isolation
Clinical Study IdentifierNCT04282850
SponsorJohns Hopkins University
Last Modified on19 February 2024

Eligibility

Yes No Not Sure

Inclusion Criteria

between 18 to 90 years of age, male or female
Left Ventricular Ejection Fraction (LVEF) > 50% by echocardiogram during routine screening or within 12 months prior to enrollment day
Symptoms of heart failure requiring treatment with diuretic therapy for at least 30 days preceding enrollment
Symptomatic paroxysmal or persistent atrial fibrillation
Paroxysmal atrial fibrillation defined as recurrent AF (at least 2 episodes) that terminated spontaneously within 7 days
Persistent AF was defined as AF which is sustained beyond 7 days, or lasting less than 7 days but necessitating pharmacologic or electrical cardioversion
Included within the category of persistent AF is "long-standing persistent AF" defined as continuous AF of greater than 1 year in duration
AF episodes had to be documented in the last 3 months prior to enrollment by ECG, Holter monitor, Loop recorder, memory of the implanted device, or any suitable device
Current symptoms of heart failure (NYHA II-IV) at the enrollment visit (Visit 1)
Structural heart disease evidenced by one or both of the following echocardiographic findings (done during the transthoracic echocardiography (TTE) within 6 months of enrollment)
Left atrial enlargement (LAE) defined as LA width > 3.8 cm or LA length > 5.0 cm, or LA area > 20 cm2 or LA volume > 55 mL or LA volume index > 29 ml/m2. (of note, LA length greater than 6.0 cm will be excluded)
Left ventricular hypertrophy (LVH) defined by septal thickness or posterior wall thickness > 1.0 cm
And at least one of the following
A heart failure hospitalization lasting over 12 hours and including intravenous diuretics at a healthcare facility within 12 months prior to the enrollment visit
An elevated pro-brain natriuretic peptide (BNP) (>100 pg/mL, or N-terminal pro b-type natriuretic peptide (NT-proBNP)>300 pg/mL)
Hemodynamic testing consistent with HFpEF physiology including pulmonary capillary wedge pressure (PCWP) (or LVEDP) 15 mmHg

Exclusion Criteria

Previous left heart ablation procedure for AF
Contraindication to chronic anticoagulation therapy or heparin
Longstanding atrial fibrillation, defined here as greater than 3 years of persistent atrial fibrillation
Severe left atrial dilatation, with LA length > 6.0 cm, optimally from parasternal long view
Acute coronary syndrome within 4 weeks as defined by electrocardiographic (ECG) ST segment depression or prominent T-wave inversion and/or positive biomarkers of necrosis (e.g. troponin) in the absence of ST-segment elevation and in an appropriate clinical setting (chest discomfort or angina equivalent)
Cardiac surgery, angioplasty, or cerebrovascular accident within 4 weeks prior to enrollment
Planned cardiovascular intervention
Listed for heart transplant
Cardiac assist device implanted or need for mechanical hemodynamic support or inpatient admission
Life expectancy less than 1 year
Uncontrolled hypertension, defined as resting systolic blood pressure >190 and/or resting diastolic pressure>110
Chronic Kidney Disease (CKD) stage 4-5 (GFR<25 ml/min/1.73m2), or on hemodialysis
Cardiac diagnosis in addition to or other than HFpEF
Active myocarditis
Hypertrophic obstructive cardiomyopathy
Severe valvular disease
Restrictive or constrictive cardiomyopathy, including known amyloidosis, sarcoidosis, hemochromatosis
Complex congenital heart disease
Constrictive pericarditis
Severe pulmonary hypertension (RVSP > 60 mmHg), not secondary to HFpEF
Non-cardiac pulmonary edema
Clinical evidence of digoxin toxicity
Sepsis
Inability to comply with planned study procedures
Pregnancy or nursing mothers
Uncontrolled hypothyroidism or hyperthyroidism
BMI of >65 kg/m2
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