Ultra‐Early Recurrence of Atrial Fibrillation After Direct Cardioversion Predicts Late Recurrence After Ablation for Persistent Atrial Fibrillation

Hiroto Sugiyama; Yoshimi Onishi; Tatsuya Onuki; Shuhei Arai; Kosuke Yoshikawa; Hiroshi Mase; Yuya Nakamura; Masaaki Kurata; Yoshitaka Iso; Taku Asano; Hiroshi Suzuki; Toshiro Shinke

doi:10.1002/joa3.70212

October 1, 2025Journal of ArrhythmiaOpen Access

Ultra‐Early Recurrence of Atrial Fibrillation After Direct Cardioversion Predicts Late Recurrence After Ablation for Persistent Atrial Fibrillation

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Why the study?

Does ultra-early recurrence of AF (URAF) after direct cardioversion predict late recurrence of atrial arrhythmias in patients undergoing first-time PVI for persistent AF?

Structured PICO

Does ultra-early recurrence of AF (URAF) after direct cardioversion predict late recurrence of atrial arrhythmias in patients undergoing first-time PVI for persistent AF?

P

Population

104 patients undergoing first-time pulmonary vein isolation (PVI) for persistent or long-standing persistent atrial fibrillation

I

Intervention

Presence of ultra-early recurrence of AF (URAF), defined as recurrence within 10 seconds after direct current cardioversion under deep sedation

C

Comparator

Absence of URAF (URAF-negative patients)

O

Outcome

Recurrence of atrial arrhythmias at 12 months postablation

Ultra-early recurrence of AF (within 10 seconds) after direct cardioversion is a strong independent predictor of late arrhythmia recurrence following first-time pulmonary vein isolation for persistent AF.

Limitations

Retrospective design
Small sample size requiring prospective validation in larger cohorts

Implication

URAF may flag high-risk patients post-cardioversion; hypothesis-generating for risk stratification in persistent AF and should not yet change practice.

Abstract

Background Although immediate recurrence of atrial fibrillation (IRAF) after cardioversion has been proposed as a surrogate for atrial substrate vulnerability, its broad definition may insufficiently discriminate patients at highest risk of postablation recurrence. We introduced the concept of ultra‐early recurrence of AF (URAF)—defined as recurrence within 10 s after direct current cardioversion (CV) under deep sedation—as a novel marker of advanced remodeling in persistent atrial fibrillation (AF). Objective To evaluate whether URAF independently predicts late recurrence following pulmonary vein isolation (PVI) in patients with persistent or long‐standing persistent AF. Methods We retrospectively analyzed 104 patients undergoing first‐time PVI for persistent AF. Among 93 patients who underwent external CV, URAF, and IRAF were defined as AF recurrence within 10 and 90 s, respectively. Recurrence of atrial arrhythmias was assessed at 12 m postablation. Results URAF was observed in 10/104 patients (9.6%) and was associated with higher 12‐m recurrence compared with URAF‐negative patients (50% vs. 18%, p = 0.02), whereas IRAF (20/104, 19.2%) showed no significant difference (30% vs. 19%, p = 0.28). On multivariable logistic regression, URAF (Odds Ratio (OR): 4.8; 95% Confidence Interval (CI): 1.16–19.98; p = 0.029) and long‐standing AF (OR: 5.5; 95% CI: 1.70–17.78; p = 0.004) emerged as independent predictors of recurrence. Kaplan–Meier analysis showed worse recurrence‐free survival for URAF (log‐rank p = 0.02; HR 4.5, 95% CI 1.18–17.41). Conclusion URAF may represent a promising intra‐procedural marker associated with post‐ablation recurrence in persistent AF, but prospective validation in larger cohorts is required.