Effects of Atrial Fibrillation Ablation for Heart Failure With Preserved Ejection Fraction: Insights From CABANA

BACKGROUND Atrial fibrillation (AF) ablation is Class I recommendation in selected heart failure (HF) patients with reduced ejection fraction; less is known in heart failure with preserved ejection fraction (HFpEF). OBJECTIVES The aim of this study was to investigate the effects of AF ablation in patients with HFpEF. METHODS The CABANA (Catheter Ablation vs Antiarrhythmic Drug Therapy for Atrial Fibrillation) trial randomized patients with cardiovascular risk factors for stroke to AF ablation vs drug therapy. The presence of a high likelihood of HFpEF at enrollment was determined by a modified H2FPEF score of >= 6. Treatment effects of baseline HFpEF likelihood on the AF ablation for death and cardiovascular admission, AF recurrence, and functional status were assessed. RESULTS A total of 1,763 patients were included in the analysis. A high modified H2FPEF score (55% of the entire cohort) resulted in a significant treatment effect modulation (P for interaction 1/4 0.027), with a lower risk for cardiovascular hospitalization or death in patients with a high likelihood of HFpEF (HR: 0.82 [95% CI: 0.69-0.98]; P 1/4 0.025), but not in patients without (HR: 1.00 [95% CI: 0.82-1.22]; P 1/4 0.987). Although patients with a high likelihood of HFpEF were at a higher risk for AF recurrence, the greatest treatment effect of AF ablation on AF recurrence was observed in patients with a high likelihood of HFpEF (P for interaction 1/4 0.035). In a sensitivity analysis in a subset of patients with echocardiographic evidence of HFpEF (n 1/4 225), a similar treatment interaction was found. CONCLUSIONS In patients undergoing AF ablation, the presence of underlying HFpEF (either by HFpEF probability or defined by echocardiography) was associated with a larger benefit with AF ablation on clinical outcome, AF recurrence, and functional status. (Catheter Ablation vs Antiarrhythmic Drug Therapy for Atrial Fibrillation [CABANA]; NCT00911508) (JACC Heart Fail. 2025;13:785-794) (c) 2025 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).