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ABSTRACTThere is a rising prevalence of patients with coexisting valvular heart disease (VHD) and atrial fibrillation (AF). Anti-coagulating these patients is often a clinical challenge, as they pose a greater bleeding risk on treatment than patients without VHD, and a greater risk of stroke or systemic embolism if anticoagulation is withheld. Patients with aortic stenosis (AS), in particular, have the highest rates of stroke and bleeding risk amongst VHD subtypes. Data comparing direct oral anticoagulants (DOAC) to Warfarin in patients with various VHD subtypes and AF are limited. Available post-hoc analysis has shown that Rivaroxaban may be associated with more major bleeding when used in patients with AS, mitral regurgitation (MR), or aortic regurgitation (AR), but similar rates of stroke or systemic embolism compared to Warfarin. Apixaban was found to have comparable outcomes with Warfarin in patients with AS, MR, or AR. Although Dabigatran and Edoxaban have similar safety and efficacy profiles to Warfarin in VHD patients, there are no available outcome data by valve disease subtype, particularly AS, which is the focus of our review. Further well-powered randomized trials evaluating various oral anticoagulant regimens are needed for the growing population of patients with AS and AF.

Introduction:Increasing evidence has suggested improved outcomes in atrial fibrillation (AF) patients with heart failure (HF) undergoing catheter ablation (CA) as compared to medical therapy. We sought to investigate the benefit of CA on outcomes of patients with AF and HF as compared to medical therapy.Methods:A systematic review of PubMed, Embase, and Cochrane Central Register of Clinical Trials was performed for clinical studies evaluating the benefit of CA for patients with AF and HF. Primary endpoint was all-cause mortality. Secondary endpoints included atrial-arrhythmia recurrence and improvement in left ventricular ejection fraction (LVEF).Results:Eight randomized controlled trials were included with a total of 2121 patients (mean age: 65 ± 5 years; 72% male). Mean follow-up duration was 32.9 ± 14.5 months. All-cause mortality in patients who underwent CA was significantly lower than in the medical treatment group (8.8% vs. 13.5%, RR 0.65, 95% CI 0.51-0.83, P=0.0005). A 35% relative risk reduction and 4.7% absolute risk reduction in all-cause mortality was observed with CA. Rates of atrial-arrhythmia recurrence were significantly lower in the CA group (39.9% vs 69.6%, RR 0.55, 95% CI 0.40-0.76, P=0.0003). Improvement in LVEF was significantly higher in patients undergoing CA (+9.4 ±7.6%) as compared to conventional treatment (+3.3±8%) (Mean difference 6.2, 95% CI 3.6-8.8, P<0.00001).Conclusion:CA for AF in patients with HF decreases all-cause mortality, improves atrial-arrhythmia recurrence rate and LVEF when compared to medical management. CA should be considered the treatment of choice to improve survival in this select group of patients.Central Illustration summarizing study outcomes.A) All-cause mortality; B) Change in left ventricular ejection fraction; C) Atrial-arrhythmia recurrence1

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