Arq Bras Cardiol abc Arquivos Brasileiros de Cardiologia Arq. Bras. Cardiol. 0066-782X 1678-4170 Sociedade Brasileira de Cardiologia - SBC FpTQ6tgtshGKf8NGQZjQqhh S0066-782X2024000100203 00203 10.36660/abc.20230820 Minieditorial Será a Ablação por Cateter para Fibrilação Atrial em Pacientes com Insuficiência Cardíaca e Fração de Ejeção Reduzida uma Boa Opção Terapêutica? 0000-0003-3378-0771 Couceiro Sergio Menezes 1 2 0000-0003-3998-8813 Sant'Anna Fernando Mendes 2 3 Universidade Federal Fluminense Cabo Frio RJ Brasil Universidade Federal Fluminense – Cardiologia, Cabo Frio, RJ – Brasil Hospital Santa Izabel Cabo Frio RJ Brasil Hospital Santa Izabel – Cardiologia, Cabo Frio, RJ – Brasil Universidade Federal do Rio de Janeiro Macaé RJ Brasil Universidade Federal do Rio de Janeiro, Campus Macaé, Macaé, RJ – Brasil Correspondência: Sergio Menezes Couceiro • Universidade Federal Fluminense – Cardiologia – Rua Raul Veiga, 5, sala 203. CEP 28907-090, Cabo Frio, RJ – Brasil. E-mail: sergiomenezes.card@hotmail.com 04 03 2024 2024 121 1 e20230820 26 11 2023 06 12 2023 06 12 2023 This is an open-access article distributed under the terms of the Creative Commons Attribution License Palavras-chave Fibrilação Atrial Insuficiência Cardíaca Ablação por Cateter Metanálise

O artigo foi bem escrito, interessante, tem relevância e validade e teve como objetivo comparar resultados obtidos através de metanálises de ensaios randomizados controlados sobre ablação por cateter em pacientes com fração de ejeção do ventrículo esquerdo inferior a 45%.1,2

Os métodos utilizados foram interessantes e procuraram responder à questão principal. Eles buscaram na literatura estudos que comparassem ablação por cateter (AC) com terapia médica em pacientes com fibrilação atrial (FA) com (fração de ejeção do ventrículo esquerdo) FEVE ≤45%. Foi realizada uma metanálise de 7 ensaios clínicos, incluindo 1.163 pacientes com FA e insuficiência cardíaca (IC). Todos os testes foram bilaterais e apenas um valor p <0,05 foi considerado estatisticamente significativo.

O autor utilizou a metodologia PRISMA,3 e os dados são incorporados ao artigo de forma comparativa e abordam as 7 metanálises selecionadas.

Foram incluídos apenas ensaios clínicos randomizados prospectivos e os critérios de inclusão foram estudos clínicos que incluíssem pacientes com FA com FEVE ≤45%. O grupo intervenção utilizou ablação por cateter para controle do ritmo (o principal procedimento foi o isolamento das veias). O grupo controle utilizou terapia médica apenas para tratamento, e os estudos relataram pelo menos um desfecho cardiovascular.

Os desfechos clínicos desta metanálise foram mortalidade por todas as causas, hospitalização por IC, recorrência de FA, melhora na FEVE e alterações na distância percorrida no teste de caminhada de 6 minutos (TC6M) e nos escores do Minnesota Living with Heart Failure Questionnaire (MLHFQ).

Isso chama nossa atenção e levanta a questão se a terapia não é uniforme entre os estudos, e nem todos levam em consideração a presença de BRE ou tamanho do átrio esquerdo, o tempo de início e o tipo de FA.

Observamos a necessidade de discriminar a causa da IC isquêmica ou não isquêmica e aplicar uma correção nos resultados.

A comparação dos ensaios CASTLE-AF4 e RAFT-HF5 revela heterogeneidade que foi corrigida, e a não heterogeneidade foi observada somente após exclusão do ensaio ARC-HF em relação à recorrência de FA.

Somente após ajuste e correção com exclusão do AMICA TRIAL6 é que conseguiram obter aumento no tempo de caminhada do teste de caminhada de 6 minutos.

Os autores concluíram que, em comparação com a terapia médica, a AC para FA em pacientes com IC foi associada a um menor risco de mortalidade por todas as causas, hospitalização por IC e recorrência de FA, além de melhorias mais significativas na FEVE e na qualidade de vida, achado que não foi corroborado por estudos mais robustos e com desenho específico.7-11

A subanálise revelou que pacientes com disfunção ventricular esquerda mais leve poderiam se beneficiar mais da ablação de FA do que pacientes com doenças mais graves, mas com baixo poder estatístico.

Minieditorial referente ao artigo: Ablação por Cateter para Fibrilação Atrial em Pacientes com Fração de Ejeção do Ventrículo Esquerdo ≤ 45%: Uma Metanálise de Ensaios Clínicos Randomizados

 Referências Cui Y Yao J Zhang J Liu Z Chen T Zhou Y Catheter Ablation for Atrial Fibrillation in Patients with Left Ventricular Ejection Fraction ≤ 45%: A Meta-Analysis of Randomized Controlled Trials Arq Bras Cardiol 2024 121 1 e20230214 https://doi.org/10.36660/abc.20230214 1 Cui Y, Yao J, Zhang J, Liu Z, Chen T, Zhou Y. Catheter Ablation for Atrial Fibrillation in Patients with Left Ventricular Ejection Fraction ≤ 45%: A Meta-Analysis of Randomized Controlled Trials. Arq Bras Cardiol. 2024; 121(1):e20230214. DOI: https://doi.org/10.36660/abc.20230214. Jones DG Haldar SK Hussain W Sharma R Francis DP Rahman-Haley SL A Randomized Trial to Assess Catheter Ablation versus Rate Control in the Management of Persistent Atrial Fibrillation in Heart Failure J Am Coll Cardiol 2013 61 18 1894 1903 10.1016/j.jacc.2013.01.069 2 Jones DG, Haldar SK, Hussain W, Sharma R, Francis DP, Rahman-Haley SL, et al. A Randomized Trial to Assess Catheter Ablation versus Rate Control in the Management of Persistent Atrial Fibrillation in Heart Failure. J Am Coll Cardiol. 2013;61(18):1894-903. doi: 10.1016/j.jacc.2013.01.069. Parkash R Wells GA Rouleau J Talajic M Essebag V Skanes A Randomized Ablation-Based Rhythm-Control versus Rate-Control Trial in Patients with Heart Failure and Atrial Fibrillation: Results from the RAFT-AF Trial Circulation 2022 145 23 1693 1704 10.1161/CIRCULATIONAHA.121.057095 3 Parkash R, Wells GA, Rouleau J, Talajic M, Essebag V, Skanes A, et al. Randomized Ablation-Based Rhythm-Control versus Rate-Control Trial in Patients with Heart Failure and Atrial Fibrillation: Results from the RAFT-AF Trial. Circulation. 2022;145(23):1693-704. doi: 10.1161/CIRCULATIONAHA.121.057095. Packer DL Piccini JP Monahan KH Al-Khalidi HR Silverstein AP Noseworthy PA Ablation versus Drug Therapy for Atrial Fibrillation in Heart Failure: Results from the CABANA Trial Circulation 2021 143 14 1377 1390 10.1161/CIRCULATIONAHA.120.050991 4 Packer DL, Piccini JP, Monahan KH, Al-Khalidi HR, Silverstein AP, Noseworthy PA, et al. Ablation versus Drug Therapy for Atrial Fibrillation in Heart Failure: Results from the CABANA Trial. Circulation. 2021;143(14):1377-90. doi: 10.1161/CIRCULATIONAHA.120.050991. Liberati A Altman DG Tetzlaff J Mulrow C Gøtzsche PC Ioannidis JP The PRISMA Statement for Reporting Systematic Reviews and Meta-Analyses of Studies that Evaluate Healthcare Interventions: Explanation and Elaboration BMJ 2009 339 b2700 b2700 10.1136/bmj.b2700 5 Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, et al. The PRISMA Statement for Reporting Systematic Reviews and Meta-Analyses of Studies that Evaluate Healthcare Interventions: Explanation and Elaboration. BMJ. 2009;339:b2700. doi: 10.1136/bmj.b2700. Di Biase L Mohanty P Mohanty S Santangeli P Trivedi C Lakkireddy D Ablation versus Amiodarone for Treatment of Persistent Atrial Fibrillation in Patients with Congestive Heart Failure and an Implanted Device: Results from the AATAC Multicenter Randomized Trial Circulation 2016 133 17 1637 1644 10.1161/CIRCULATIONAHA.115.019406 6 Di Biase L, Mohanty P, Mohanty S, Santangeli P, Trivedi C, Lakkireddy D, et al. Ablation versus Amiodarone for Treatment of Persistent Atrial Fibrillation in Patients with Congestive Heart Failure and an Implanted Device: Results from the AATAC Multicenter Randomized Trial. Circulation. 2016;133(17):1637-44. doi: 10.1161/CIRCULATIONAHA.115.019406. Prabhu S Taylor AJ Costello BT Kaye DM McLellan AJA Voskoboinik A Catheter Ablation versus Medical Rate Control in Atrial Fibrillation and Systolic Dysfunction: The CAMERA-MRI Study J Am Coll Cardiol 2017 70 16 1949 1961 10.1016/j.jacc.2017.08.041 7 Prabhu S, Taylor AJ, Costello BT, Kaye DM, McLellan AJA, Voskoboinik A, et al. Catheter Ablation versus Medical Rate Control in Atrial Fibrillation and Systolic Dysfunction: The CAMERA-MRI Study. J Am Coll Cardiol. 2017;70(16):1949-61. doi: 10.1016/j.jacc.2017.08.041. Kuck KH Merkely B Zahn R Arentz T Seidl K Schlüter M Catheter Ablation versus Best Medical Therapy in Patients with Persistent Atrial Fibrillation and Congestive Heart Failure: The Randomized AMICA Trial Circ Arrhythm Electrophysiol 2019 12 12 e007731 10.1161/CIRCEP.119.007731 8 Kuck KH, Merkely B, Zahn R, Arentz T, Seidl K, Schlüter M, et al. 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Sohns C Zintl K Zhao Y Dagher L Andresen D Siebels J Impact of Left Ventricular Function and Heart Failure Symptoms on Outcomes Post Ablation of Atrial Fibrillation in Heart Failure: CASTLE-AF Trial Circ Arrhythm Electrophysiol 2020 13 10 e008461 10.1161/CIRCEP.120.008461 10 Sohns C, Zintl K, Zhao Y, Dagher L, Andresen D, Siebels J, et al. Impact of Left Ventricular Function and Heart Failure Symptoms on Outcomes Post Ablation of Atrial Fibrillation in Heart Failure: CASTLE-AF Trial. Circ Arrhythm Electrophysiol. 2020;13(10):e008461. doi: 10.1161/CIRCEP.120.008461. Richter S Di Biase L Hindricks G Atrial Fibrillation Ablation in Heart Failure Eur Heart J 2019 40 8 663 671 10.1093/eurheartj/ehy778 11 Richter S, Di Biase L, Hindricks G. Atrial Fibrillation Ablation in Heart Failure. Eur Heart J. 2019;40(8):663-71. doi: 10.1093/eurheartj/ehy778. Short Editorial Is Catheter Ablation for Atrial Fibrillation in Patients with Heart Failure and Reduced Ejection Fraction a Good Therapeutic Option? 0000-0003-3378-0771 Couceiro Sergio Menezes 1 2 0000-0003-3998-8813 Sant'Anna Fernando Mendes 2 3 Cabo Frio RJ Brazil Universidade Federal Fluminense – Cardiologia, Cabo Frio, RJ – Brazil Cabo Frio RJ Brazil Hospital Santa Izabel – Cardiologia, Cabo Frio, RJ – Brazil Macaé RJ Brazil Universidade Federal do Rio de Janeiro, Campus Macaé, Macaé, RJ – Brazil Mailing Address: Sergio Menezes Couceiro • Universidade Federal Fluminense – Cardiologia – Rua Raul Veiga, 5, sala 203. Postal Code 28907-090, Cabo Frio, RJ – Brazil. E-mail: sergiomenezes.card@hotmail.com Keywords Atrial Fibrillation Heart Failure Catheter Ablation Meta-Analysis

The article was well written, interesting, has relevance and validity and aimed to compare results obtained through meta-analyses of randomized controlled trials on catheter ablation in patients with left ventricular ejection fraction below 45%.1,2

The methods used were interesting and sought to answer the main question. They searched the literature for studies that compared catheter ablation (CA) with medical therapy in patients with atrial fibrillation (AF) with left ventricular ejection fraction (LVEF) ≤45%. A meta-analysis of 7 clinical trials was performed, including 1,163 patients with AF and heart failure (HF). All tests were two-sided, and only a p value <0.05 was considered statistically significant.

The author used the PRISMA3 methodology, and the data is incorporated into the article comparatively and addresses the 7 selected meta-analyses.

Only prospective randomized clinical trials were included, and the inclusion criteria were clinical studies that included AF patients with LVEF ≤45%. The intervention group used catheter ablation for rhythm control (the main procedure was vein isolation). The control group used medical therapy only for treatment, and studies reported at least one cardiovascular outcome.

The clinical outcomes of this meta-analysis were all-cause mortality, HF hospitalization, AF recurrence, improvement in LVEF, and changes in 6-minute walk distance (6MWT) and Minnesota Living with Heart Failure Questionnaire (MLHFQ) scores.

It catches our attention and raises the question as to whether therapy is not uniform across studies, and not all of them take into account the presence of LBBB or left atrium size, time since onset, and type of AF.

We observed the need to discriminate the cause of ischemic or non-ischemic HF and apply a correction to the results.

Comparing the CASTLE-AF4 and RAFT-HF5 trials brings out heterogenicity that was corrected, and non-heterogenicity was observed only after excluding the ARC-HF trial in relation to AF recurrence.

Only after adjusting and correcting with the exclusion of the AMICA TRIAL6 were they able to obtain an increase in the walking time of the 6-minute walk test.

The authors concluded that compared with medical therapy, AC for AF in patients with HF was associated with a lower risk of all-cause mortality, hospitalization for HF, and AF recurrence and more significant improvements in LVEF and quality of life, a finding that was not corroborated by more robust studies with a specific design.7-11

The subanalysis revealed that patients with milder left ventricular failure dysfunction could benefit more from AF ablation than patients with more severe diseases but with low statistical power.

Short Editorial related to the article: Catheter Ablation for Atrial Fibrillation in Patients with Left Ventricular Ejection Fraction ≤ 45%: A Meta-Analysis of Randomized Controlled Trials