Key result
Staged endo-epicardial ablation yields ~49% freedom from AF recurrence at 36 months.
Why the study?
Rhythm outcomes after staged endo-epicardial ablation for persistent and long-standing persistent AF are traditionally assessed using binary recurrence definitions that may not reflect the clinical relevance of residual arrhythmia.
Does staged endo-epicardial ablation improve freedom from AF recurrence and reduce AF burden in patients with symptomatic non-paroxysmal AF?
Cohort (n=89)
Yes
Does staged endo-epicardial ablation improve freedom from AF recurrence and reduce AF burden in patients with symptomatic non-paroxysmal AF?
Continuous monitoring reveals that while binary AF recurrence is common after staged endo-epicardial ablation, the cumulative AF burden remains low, suggesting burden is a more clinically meaningful metric.
Answers are grounded in this paper and cite their sources.
Low AF burden despite recurrences after staged endo-epicardial ablation challenges binary recurrence endpoints; leaves open its role in persistent AF.
BACKGROUND: In patients with persistent and long-standing persistent atrial fibrillation (AF), staged endo-epicardial ablation is increasingly used to treat complex arrhythmogenic substrates. However, rhythm outcomes are traditionally assessed using binary recurrence definitions that may not reflect the clinical relevance of residual arrhythmia. AIMS: Our aim was to evaluate AF recurrence and AF burden using continuous implantable loop recorder (ILR) monitoring after staged endo-epicardial ablation. METHODS: In this prospective study, 89 consecutive patients with symptomatic non-paroxysmal AF undergoing staged thoracoscopic and transcatheter ablation at Santa Chiara Hospital, Trento, between 2019 and 2023 were included. All patients received continuous rhythm monitoring with an ILR. The primary endpoint was freedom from AF episodes lasting >30 seconds after the blanking period. AF burden was assessed using predefined thresholds of 0.1% and 5%. RESULTS: 89 patients (mean age 65 [± 9] years; 85% male) were analyzed. Freedom from AF recurrence was 84.2% at 6 months and 48.5% at 36 months. Continuous monitoring showed a substantial discrepancy between binary AF recurrence and cumulative AF burden. Despite documented recurrences, most patients maintained AF burden <5% during follow-up. Several patients classified as failures by the >30-second criterion showed minimal cumulative AF burden. An AF burden >0.1% was associated with cardiovascular rehospitalization. Symptoms improved markedly during follow-up, including in patients with ILR-documented recurrence. CONCLUSIONS: Continuous monitoring after staged endo-epicardial ablation shows a substantial and durable reduction in AF burden despite recurrences detected by conventional criteria. AF burden may represent a more clinically meaningful measure of rhythm control than traditional recurrence definitions.
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Marini et al. (2026) conducted a cohort in symptomatic non-paroxysmal atrial fibrillation (n=89). Staged endo-epicardial ablation was evaluated on Freedom from AF episodes lasting >30 seconds after the blanking period at 36 months. Staged endo-epicardial ablation resulted in 48.5% freedom from AF recurrence at 36 months, with most patients maintaining an AF burden <5% despite documented recurrences.
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