Diagnosis-to-ablation time as a predictor of success: early choice for pulmonary vein isolation and long-term outcome in atrial fibrillation: results from the Middelheim-PVI Registry

Aims: The aim of the study is to define long-term outcome of pulmonary vein isolation (PVI) in atrial fibrillation (AF) and to determine whether time window between AF diagnosis and PVI affects outcome. Methods and results: Consecutive AF patients undergoing PVI (2006-14) were followed for 5 years. Primary outcome was clinical success, defined as freedom of documented AF without anti-arrhythmic drugs respecting a 1-month blanking period. A 1000 patients were included (age 60 ± 10 years, CHA2DS2-VASc score 1 ± 1). The cohort was divided in four quartiles (Q) according to the diagnosis-to-ablation time (DAT): Q1 DAT 0-11 months (N = 244), Q2 DAT 12-≤33 months (N = 254), Q3 DAT 34-≤70 months (N = 252) and Q4 DAT 71-360 months (N = 250). Mean follow-up was 44.3±21.0 months. At 5 years, clinical success was achieved in 45.2 ± 2.0% of patients. Independent predictors of clinical success were AF type (HR = 0.61; 95%CI 0.50-0.74; P < 0.0001), left atrial size (HR = 1.03; 95%CI 1.02-1.05; P < 0.0001), DAT (HR = 1.00; 95%CI 1.00-1.00; P = 0.001), ablation technique (P = 0.012), and year of ablation (HR = 0.93; 95%CI 0.86-1.00; P = 0.045) in multivariable-adjusted analysis. The highest clinical success was achieved when PVI was performed within the first year, and gradually declined with increasing DAT: 55.9 ± 4.6% for Q1, 46.9 ± 4.0% for Q2, 45.5 ± 3.6% for Q3, and 35.5 ± 3.6% for Q4 (P < 0.001). Conclusion: Long-term success rate of PVI is 45.2 ± 2.0%. Shorter diagnosis-to-ablation times are associated with better clinical success. Our data advocate for early PVI following diagnosis of AF.