Robotic-assisted local epicardial radiofrequency ablation vs. catheter ablation first in patients with persistent and long-standing persistent atrial fibrillation: a multicenter retrospective study

Background - Despite rate- or rhythm-control therapy and even successful initial catheter ablation, >40% of patients with persistent (Ps) or long-standing persistent (LS-Ps) atrial fibrillation (AF) experience early recurrence. Robotic-assisted local epicardial radiofrequency ablation (LERFA) is an established first stage of hybrid AF ablation, with baseline and progressive impedance drops as intraoperative predictors of efficacy. Purpose - To assess outcomes of robotic-assisted hybrid LERFA vs catheter ablation as first-line treatment for Ps and LS-Ps AF. Methods - Retrospective analysis of 203 consecutive patients who underwent robotic-assisted hybrid LERFA as either first treatment or following failed catheter ablation for Ps or LS-Ps AF. After excluding those lacking a completed procedure, active clinical and extended rhythm follow-up, 161 patients were stratified as "de novo" (DN; no prior catheter ablation, <12 months from first EP evaluation) vs "prior catheter ablation" (PCA; ≥1 prior ablations and medical trials, >12 months from first EP evaluation). Rhythm follow-up (Holter, PM/ICD, or loop recorder) was obtained at 3, 12, and 24 months. Primary outcome was freedom from atrial arrhythmia >30 s, off class I/III antiarrhythmic drugs (AAD). Secondary endpoints included re-interventions, AF-related readmissions, discontinuation of AAD and oral anticoagulation (OAC). Normality was assessed by Kolmogorov-Smirnov test. Continuous variables were expressed as mean (±SD) or median (IQ range), as appropriate. Comparisons between groups were performed using the t-test or Mann-Whitney U test for continuous variables and chi-square for categorical variables. Freedom from AF was analyzed by Kaplan-Meier method with log-rank test. Results - There were 59 patients in the DN group (age 65 years, 81.4% M) and 102 patients in the PCA group (age 67, 72.6% M). There were no differences in terms of BMI, LVEF, CHADs-DS2-VASc, HASBLED and LAVI (Table 1). Duration of AF was significantly longer among PCA patients (77 vs 24 months, p<0.001), with an average of 1.8 (1-4) ablations. Follow-up was complete, with no mortality observed. DN patients had significantly higher class I/III AAD discontinuation at 12 months (82.4 vs 50%, p=0.049), benefited from fewer re-interventions (5.1 vs 13.7%, p=0.14) as well as AF-related readmissions (5.1 vs 17.6%, p<0.05), and higher OAC discontinuation rate (91.2 vs 64.2%, p<0.05). At 24 months, de novo patients experienced a significant difference in freedom from AF (log-rank p=0.003, Fig. 1). Conclusions - Robotic-assisted LERFA as initial hybrid approach to Ps and Ls-PS AF may be associated with superior rhythm and clinical outcomes. Early multidisciplinary consideration of a hybrid strategy could enhance arrhythmia-free survival, reduce reinterventions, AF-related readmissions, favoring discontinuation of both AAD and OAC. Prolonged medical management with repeated catheter ablations may hinder a subsequent hybrid approach.