Meta-analysis of clinical outcomes of electrical cardioversion and catheter ablation in patients with atrial fibrillation and chronic kidney disease

Background: Chronic kidney disease (CKD) is associated with adverse outcomes in presence of atrial fibrillation (AF). However, the literature shows limited data on non-pharmacological management of AF in CKD patients. Aim: summarizing the available data on outcomes associated with electrical cardioversion (ECV) and AF catheter ablation (CA) in CKD patients. Methods: We searched MEDLINE and the Cochrane Central Register of Controlled Trials and performed a meta-analysis. The primary outcome was recurrence of AF. The secondary outcomes were occurrence of thromboembolic events (TEs) and estimated glomerular filtration rate (eGFR) modification. Results: Literature search yielded 26 eligible papers: 22 on CA and 4 concerning ECV. CKD patients presented more AF recurrences 30 days after ECV (OR 2.62, 95%CI 1.28-5.34; p <0.001). Patients with eGFR<60-68 ml/min and on dialysis presented a higher incidence of AF recurrences after CA, median follow up 26.0 and 29.9 months (HR 1.75, 95%CI 1.46-2.09, p <0.001; and HR 1.69, 95%CI 1.22-2.33, p <0.001; respectively). Peri-procedural TEs were rare and not associated with CKD or dialysis. However, patients with CKD were at increased risk for delayed TEs after CA (HR 2.61, 95%CI 1.04-6.54; p <0.001). No significant modification of eGFR was associated with ECV or CA in the overall population. Conclusion: ECV and CA for sinus rhythm restoration/maintenance in AF patients, albeit theoretically promising, seem to be associated with lower efficacy at medium to long-term in patients with CKD. Further studies are needed to better define the role of ECV and CA in CKD.