Catheter ablation of atrial fibrillation in patients with hypertrophic cardiomyopathy: atrial fibrillation type determines the success rate

Background: Atrial fibrillation (AF) in patients with hypertrophic cardiomyopathy (HCM) is generally associated with deterioration of the clinical status, functional capacity, and quality of life. It is also an independent risk factor for stroke and death. Studies evaluating the effectiveness of AF ablation in this cohort are relatively scant, have included relatively few patients, and their results are somewhat conflicting. Thus, the aim of this study was to assess the safety and efficacy of catheter ablation of AF in patients with HCM. Methods: Thirty patients (10 females; mean age 48.7 +/- 11 years) with drug-refractory paroxysmal (n = 14), persistent (n = 7), or long-persistent (> 1 year; n = 9) AF were prospectively recruited into the study. Eleven patients were in New York Heart Association (NYHA) class I, 13 patients were in NYHA class II, and 6 patients were in NYHA class III. Mean atrial volume was 180 +/- 47 mL, interventricular septum thickness was 20.5 +/- 6.3 mm, and left atrial area was 29.8 +/- 6.2 cm(2). Ablation protocol was adjusted to the clinical and electrophysiological status of the patients. Pulmonary vein isolation and bidirectional cavo-tricuspid isthmus block were performed in all patients. In addition, left atrial linear lesions were created and complex fragmented atrial potentials were ablated in patients with persistent and long-persistent AF, as well as during repeated procedures. Results: At 12 months, stable sinus rhythm (SR) was present in 16 (53%) patients, significantly more frequently in patients with paroxysmal AF (71% in SR) compared to those with persistent (57.1% in SR) or long-persistent (22% in SR) AF. A significant reduction of AF burden was observed in 85.7% of patients with paroxysmal AF, 71.4% of patients with persistent AF, and 55.5% of patients with long-persistent AF. Single procedure success rate was 33% (10 patients), and repeat ablation procedures were performed in 13 patients. No periprocedural complications occurred. Thromboembolic events were noted in 2 patients with arrhythmia recurrence during the follow-up, including stroke in 1 patient and peripheral embolism in the other patient. In both these patients, heart failure worsening was observed during these events, and anticoagulation was inadequate in one of them. Five of 16 patients in whom stable SR was observed during the follow-up were off antiarrhythmic drug therapy at final evaluation. In the other 6 patients, antiarrhythmic drug therapy was continued due to ventricular arrhythmias. Successfully treated patients more often had paroxysmal AF (successful ablation: paroxysmal AF in 10 of 16 patients; unsuccessful ablation: paroxysmal AF in 4 of 14 patients; p = 0.009) and were younger (45 +/- 11.5 years vs. 52.6 +/- 9.2 years; p = 0.046). In addition, a trend toward a reduced need for cardioversion at the end of the procedure was also observed in these patients (3 patients in the successful ablation group vs. 8 patients in the unsuccessful ablation group; p = 0.056). In multivariate regression analysis, paroxysmal AF was the only independent predictor of a successful outcome. Conclusions: Catheter ablation of AF in patients with HCM is an effective and safe therapeutic option, particularly in patients with paroxysmal AF. Effectiveness of ablation is significantly smaller in patients with persistent AF and even more so in those with long-persistent AF. Repeated procedures were often necessary. Continued antiarrhythmic drug therapy is often required due to a significant degree of atrial remodelling.