Importance Catheter 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). Objective To determine the impact of pulmonary vein isolation (PVI) with PWI vs PVI alone on outcomes in patients with HFrEF. Design, Setting, and Participants This 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 <50% and New York Heart Association class ≥II). Interventions Pulmonary vein isolation with PWI vs PVI alone. Main Outcomes and Measures The 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. Results A 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 < .01) and PVI alone (18.2% [14.1%; P < .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 Relevance The 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 Registration http://anzctr.org.au Identifier: ACTRN12616001436460.

中文翻译：

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后壁隔离在持续性心房颤动和收缩性心力衰竭导管消融中的作用：随机临床试验的二次分析。

重要性 与药物治疗相比，心房颤动 (AF) 和射血分数降低的心力衰竭 (HFrEF) 患者的导管消融可改善左心室射血分数 (LVEF) 和生存率。非随机研究报告后壁隔离 (PWI) 的成功率有所提高。目的 确定肺静脉隔离 (PVI) 联合 PWI 与单独 PVI 对 HFrEF 患者预后的影响。设计、设置和参与者 这是对 CAPLA 试验的临时二次分析，该试验是一项多中心、前瞻性、随机对照试验，涉及 3 个国家（澳大利亚、加拿大和英国）的 11 个中心。CAPLA 纳入了 338 名持续性 AF 患者，随机分为 PVI 加 PWI 组或单独 PVI 组。该亚组研究纳入了最初 CAPLA 研究中出现有症状 HFrEF 的患者（LVEF <50% 且纽约心脏协会分级≥II）。干预措施 PWI 肺静脉隔离与单独 PVI 的比较。主要结果和措施 主要终点是在 12 个月时，在不使用抗心律失常药物 (AAD) 治疗的情况下，单次消融手术后，没有任何记录超过 30 秒的房性心律失常。结果 总共确定了 98 名患有持续性 AF 和症状性 HFrEF 的患者（平均 [SD] 年龄，62.1 [9.8] 岁；79.5% 为男性；基线时平均 [SD] LVEF，34.6% [7.9%]）。12 个月后，在不使用 AAD 治疗的情况下，PVI 联合 PWI 患者中有 58.7% 的患者没有复发性房性心律失常，而单独使用 PVI 的患者这一比例为 61.5%（风险比，1.02；95% CI，0.54-1.91；P = .96）。多次手术后，无论是否接受 AAD 治疗，房性心律失常的发生率均无显着差异（PVI 加 PWI 与单独 PVI，分别为 60.9% 与 65.4%；P = 0.73）或 AF 负担（两组中中位数均为 0%；P）。 = .78）。PVI 加 PWI 的平均 LVEF 显着改善 (Δ LVEF, 19.3% [13.0%; P < .01) 和单独 PVI (18.2% [14.1%; P < .01)]，组间无差异 (P = .71) 。PVI 加 PWI 组中 65.2% 的患者左室功能正常化，而单独 PVI 组中这一比例为 50.0% (P = .13)。结论和相关性 本研究的结果表明，在 PVI 的基础上添加 PWI 并不能改善持续性 AF 和症状性 HFrEF 患者的心律失常复发或 LVEF 的恢复。无论采用何种消融策略，导管消融都与收缩功能的显着改善相关。这些结果提醒我们不要将 PWI 常规纳入因持续性 AF 进行首次导管消融的 HFrEF 患者中。试用注册 http://anzctr.org.au 标识符：ACTRN12616001436460。