Increasing time between first diagnosis of atrial fibrillation and catheter ablation adversely affects long‐term outcomes in patients with and without structural heart disease

Andrew J. Sessions; Heidi T. May; Brian G. Crandall; John Day; Michael J. Cutler; Christopher A. Groh; Leenhapong Navaravong; Ravi Ranjan; Benjamin A. Steinberg; T. Jared Bunch

doi:10.1111/jce.15810

January 14, 2023Journal of Cardiovascular Electrophysiology

Increasing time between first diagnosis of atrial fibrillation and catheter ablation adversely affects long‐term outcomes in patients with and without structural heart disease

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Why the study?

Catheter ablation is effective for AF with concurrent left ventricular dysfunction, but the optimal timing of ablation in these patients was unknown.

Does delayed catheter ablation for atrial fibrillation increase the risk of adverse outcomes compared to early ablation in patients with and without structural heart disease?

Structured PICO

Does delayed catheter ablation for atrial fibrillation increase the risk of adverse outcomes compared to early ablation in patients with and without structural heart disease?

P

Population

9,979 patients who received a catheter ablation for atrial fibrillation with at least 1 year of follow-up within the Intermountain Healthcare system, stratified by ejection fraction (EF ≤ 35%, n=1,024; EF > 35%, n=8,955).

I

Intervention

Delayed catheter ablation for atrial fibrillation (performed 181-545 days, 546-1825 days, or >1825 days from initial diagnosis)

C

Comparator

Early catheter ablation for atrial fibrillation (performed 30-180 days from initial diagnosis)

O

Outcome

All-cause mortality (death)hard clinical

Delaying catheter ablation for atrial fibrillation is associated with increased all-cause mortality, heart failure hospitalization, and stroke, supporting earlier intervention regardless of baseline ejection fraction.

Implication

Earlier AF ablation may lower mortality risk; leaves open optimal timing in HF.

Abstract

INTRODUCTION: Atrial Fibrillation (AF) is a common arrhythmia often comorbid with systolic or diastolic heart failure (HF). Catheter ablation is a more effective treatment for AF with concurrent left ventricular dysfunction, however, the optimal timing of use in these patients is unknown. METHODS: All patients that received a catheter ablation for AF(n = 9979) with 1 year of follow-up within the Intermountain Healthcare system were included. Patients with were identified by the presence of structural disease by ejection fraction (EF): EF ≤ 35% (n = 1024) and EF > 35% (n = 8955). Recursive partitioning categories were used to separate patients into clinically meaningful strata based upon time from initial AF diagnosis until ablation: 30-180(n = 2689), 2:181-545(n = 1747), 3:546-1825(n = 2941), and 4:>1825(n = 2602) days. RESULTS: The mean days from AF diagnosis to first ablation was 3.5 ± 3.8 years (EF > 35%: 3.5 ± 3.8 years, EF ≤ 35%: 3.4 ± 3.8 years, p = .66). In the EF > 35% group, delays in treatment (181-545 vs. 30-180, 546-1825 vs. 30-180, >1825 vs. 30-180 days) increased the risk of death with a hazard ratio (HR) of 2.02(p < .0001), 2.62(p < .0001), and 4.39(p < .0001) respectively with significant risks for HF hospitalization (HR:1.44-3.69), stroke (HR:1.11-2.14), and AF recurrence (HR:1.42-1.81). In patients with an EF ≤ 35%, treatment delays also significantly increased risk of death (HR 2.07-3.77) with similar trends in HF hospitalization (HR:1.63-1.09) and AF recurrence (HR:0.79-1.24). CONCLUSION: Delays in catheter ablation for AF resulted in increased all-cause mortality in all patients with differential impact observed on HF hospitalization, stroke, and AF recurrence risks by baseline EF. These data favor earlier use of ablation for AF in patients with and without structural heart disease.