Innovative technologies for transcatheter ablation of atrial fibrillation in patients with heart failure: the new age AF-HF registry

Background: Heart failure (HF) and atrial fibrillation (AF) frequently coexist, worsening each other’s clinical course. Data on catheter ablation (CA) of AF using novel ablation technologies in patients with HF remain limited. Methods: We established a prospective, multicentre international registry including patients consecutively undergoing AF CA using pulsed-field ablation, third-generation visually guided laser balloon, or the latest-generation cryoballoon between 2020 and 2025. The study group comprised patients with HF and reduced (HFrEF), moderately reduced (HFmrEF), and preserved (HFpEF) ejection fraction; patients without HF served as controls. Primary endpoints were procedural time and the rate of procedure-related adverse events; secondary endpoints were 12- and 24-months freedom from AF recurrence beyond the 3-month blanking period and from major adverse cardiac and cerebrovascular events (MACCEs). Results: Among 1,047 enrolled patients, 180 (17.2%) had HF; 886 (84.6%) had follow-up, and 400 had adjudicated MACCE data. HF patients had longer procedural (median 93.5 (70–141) vs 75 (60–105) min, p<0.001) and fluoroscopy times (19.5 (8.5–32.2) vs 10 (6.4–18) min, p<0.001) with similar complication rates (1.7% vs 2.1%, p=0.13). Freedom from AF recurrence at 12 and 24 months was significantly lower in HF patients (74.0% vs 63.2% and 57.5% vs 50.5%, p<0.001). HF was the only independent predictor of AF recurrence (HR 1.50, p=0.024), driven by HFpEF (HR 2.28, p=0.001). HF patients also showed reduced 12- and 24-month freedom from MACCEs (99.0% vs 89.0%; 98.0% vs 83.5%; p<0.001). Independent predictors of MACCEs included HFrEF (HR 14.89, p<0.001), HFpEF (HR 11.07; p=0.001), and rhythm-control discontinuation at follow-up (HR 6.9, p=0.002). Conclusions: Novel ablation technologies were safe and effective for patients with HF, and outcomes were comparable to standard systems. While both HFpEF and HFrEF increased MACCE risk, only HFpEF predicted AF recurrence post-ablation, underscoring the need for tailored rhythm-control strategies across the HF spectrum.