Catheter ablation versus no ablation for atrial fibrillation in cardiac amyloidosis: A propensity-matched cohort study

Abstract

Background: Atrial fibrillation (AF) is extremely common in cardiac amyloidosis (CA) due to amyloid infiltration and atrial electrical remodeling. We aim to compare ablation outcomes versus no-ablation in patients taking anti-arrhythmic drugs (AAD) in CA-associated AF.

Methods: Using TriNetX database (2019-2025), 5,562 patients with CA and AF were identified and divided into two groups: catheter ablation plus AADs (n=893) versus medical therapy alone (n=4,669). Baseline characteristics were adjusted and 1:1 propensity score matching was performed to account for baseline differences. Primary composite outcome included all-cause mortality, ischemic strokes, bleeding and subsequent myocardial infarction.

Results: 870 patients were included in each cohort. At 12-month follow-up, catheter ablation was associated with a significantly lower risk of the composite outcome (8.3% vs 13.2%; HR 0.591, 95% CI 0.418–0.834, p=0.002), and reduced all-cause mortality. There were no significant differences in all-cause hospitalization, emergency department visits, new-onset heart failure, atrioventricular block, or cardiac arrest. Repeat ablation or cardioversion, and subsequent pacemaker or ICD implantation were more frequent in the ablation group.

Conclusion: Catheter ablation was associated with improved short-term outcomes despite higher arrhythmia recurrence. Ablation may be considered in carefully selected patients, particularly those with earlier-stage disease or significant symptoms.